A nurse is assessing a client who is receiving IV vancomycin. The nurse notes a flushing of the neck and tachycardia. Which of the following actions should the nurse take?

Document that the client experienced an anaphylactic reaction to the medication.

Decrease the infusion rate on the IV.

Apply cold compresses to the neck area.

Change the IV infusion site.

Answer and Explanation

The Correct Answer is B

A. The symptoms described (flushing and tachycardia) are not indicative of an anaphylactic reaction, which typically includes symptoms like difficulty breathing, hives, or swelling. Documenting it as an anaphylactic reaction would be misleading and could lead to inappropriate management.
B.   Slowing the infusion rate can help mitigate the symptoms of Red Man Syndrome, which is often related to the rate of vancomycin administration. The recommended infusion rate for vancomycin is generally over at least 60 minutes, and reducing the rate can help alleviate symptoms.
C.   Applying cold compresses should help with pain but as important like documentation.
D.   The infusion should be continued and not used again for the client.

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Correct Answer is D

Explanation

Phenylephrine is an alpha-adrenergic agent. It binds onto adrenergic receptors producing a sympathetic effect that dilates the pupil. Dilation of the pupils allows for visualization of inner structures of the eye and easier access during retinal surgery.
A. Timolol is a beta-blocker eye drop used to reduce intraocular pressure in conditions like glaucoma.
B. Pilocarpine is a miotic agent (constricts the pupil) used to treat conditions like glaucoma.
C. Latanoprost is a prostaglandin analog used to lower intraocular pressure in glaucoma.

A. pruritus B. Diarrhea C. Blurred Vision D. Fatigue

Correct Answer is C

Explanation

hydroxychloroquine is a quinoline that is used to suppress the immune system in autoimmune conditions. Among its side effects, it can cause retinal toxicity that warrants stopping the medications. Blurring of vision should, therefore, be reported immediately.
A, B, and D - these are potential adverse effects of hydroxychloroquine but do not require immediate attention

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A nurse is assessing a client who is receiving IV vancomycin. The nurse notes a flushing of the neck and tachycardia. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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