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 B

Explanation

Metoclopramide is a prokinetic agent that increases the motility of the upper gastrointestinal tract. Metoclopramide helps accelerate gastric emptying and promotes movement of food through the digestive system. This action can alleviate symptoms of nausea and vomiting by reducing the likelihood of food staying in the stomach for an extended period, which can contribute to feelings of discomfort.

A. Metoclopramide does not increase or decrease gastric acid secretions.

C. Metoclopramide accelerates peristalsis or the movement of food through the gastrointestinal tract.

D. Metoclopramide increases muscle tone and GI motility

A. Monitor for increased muscle spasms. B. Discontinue medication if nausea occurs. C. Avoid driving until effects are known. D. Expect urine to turn orange.

Correct Answer is C

Explanation

Cyclobenzaprine is a muscle relaxant used to relieve muscle spasms in various musculoskeletal conditions. One of the common side effects of cyclobenzaprine is drowsiness and impaired cognitive function, which can affect the ability to operate machinery or drive safely.
A. Cyclobenzaprine is used to reduce muscle spasms, so monitoring for increased muscle spasms would not be appropriate.
B. Nausea can be a common side effect of cyclobenzaprine, but it does not typically require discontinuation of the medication unless it is severe or persistent and causing significant distress.
D. Cyclobenzaprine does not typically cause urine discoloration, so expecting urine to turn orange is not relevant to the medication.

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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

A nurse is caring for a client who has nausea and a prescription for metoclopramide intermittent IV bolus every 4 hr as needed. The client asks the nurse how metoclopramide Will relieve her nausea. Which of the following explanations should the nurse provide?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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