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 C

Explanation

Prednisone is a corticosteroid that can suppress the body's immune system increasing the client's susceptibility to infections such as upper respiratory tract infections. Flu vaccine is, therefore, important to boost immunity
A. Aspirin and Prednisone increases the risk of gastrointestinal irritation and ulceration and use together increases this risk even further.
B. Although hypokalemia is a common electrolyte abnormality observed with hypokalemia, eating more bananas is unlikely to address the issue
D. Getting a sore throat can happen due to lowered immunity but does not always happen

A. Increases bone density B. Reduces risk of infection C. Improves peripheral blood flow D. Decreases inflammation

Correct Answer is D

Explanation

corticosteroids such as prednisone are potent anti-inflammatory agents used in inflammatory conditions such as rheumatoid arthritis. This reduces the features of inflammation which include reduction of pain.
A. Prednisone reduces bone density
B. Prednisone lowers the body's immunity increasing the risk of infection
C. Prednisone increases risk of cardiovascular disease but does not directly interfere with peripheral blood

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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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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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