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

Decrease the infusion rate on the IV.

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

Change the IV infusion site.

Apply cold compresses to the neck area.

Answer and Explanation

The Correct Answer is A

Choice A reason: Decrease the Infusion Rate on the IV

Decreasing the infusion rate on the IV is the appropriate action to take when a client experiences flushing of the neck and tachycardia while receiving vancomycin. These symptoms are indicative of vancomycin flushing syndrome (VFS), also known as “red man syndrome,” which is a reaction caused by the rapid infusion of vancomycin. Slowing the infusion rate allows the body more time to metabolize the drug and can help alleviate the symptoms.

Choice B reason: Document that the Client Experienced an Anaphylactic Reaction to the Medication

Documenting that the client experienced an anaphylactic reaction is not accurate in this scenario. Vancomycin flushing syndrome is an anaphylactoid reaction, not an anaphylactic one. Anaphylactoid reactions are not mediated by IgE antibodies and do not require prior sensitization to the drug. Therefore, it is important to distinguish between the two and document the reaction correctly.

Choice C reason: Change the IV Infusion Site

Changing the IV infusion site is not necessary in this case. The symptoms of flushing and tachycardia are related to the rate of vancomycin infusion, not the site of infusion. Therefore, changing the site would not address the underlying issue.

Choice D reason: Apply Cold Compresses to the Neck Area

Applying cold compresses to the neck area may provide some symptomatic relief, but it does not address the root cause of the reaction. The primary intervention should be to slow the infusion rate to prevent further release of histamine and alleviate the symptoms.

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Correct Answer is A

Explanation

Choice A reason:

Metoprolol is a beta-blocker commonly used to treat high blood pressure (hypertension). One of its primary therapeutic effects is the reduction of blood pressure. By blocking beta-adrenergic receptors, metoprolol decreases the heart rate and the force of contraction, leading to lower blood pressure.

Choice B reason:

While metoprolol can help manage certain types of dysrhythmias by slowing the heart rate and stabilizing the heart’s rhythm, the primary therapeutic effect for which it is most commonly prescribed is the reduction of blood pressure.

Choice C reason:

Increased urine output is not a direct therapeutic effect of metoprolol. This effect is more commonly associated with diuretics, which are often used in conjunction with beta-blockers to manage hypertension and heart failure.

Choice D reason:

Decreased pulse is a potential effect of metoprolol, as it slows the heart rate. However, this is not the primary therapeutic goal. The main therapeutic effect is the reduction of blood pressure.

A. The health care proxy does not go into effect until I am incapable of making decisions. B. I have to choose a family member as my health proxy. C. I can change who I designate as my health care proxy at any time. D. If I become incapacitated, end-of-life choices will be made by my proxy.

Correct Answer is B

Explanation

Choice A reason: The Health Care Proxy Does Not Go Into Effect Until I Am Incapable of Making Decisions

This statement is correct. A health care proxy, also known as a durable power of attorney for health care, only becomes active when the individual is no longer capable of making their own medical decisions. Until that point, the individual retains full control over their health care choices1.

Choice B reason: I Have to Choose a Family Member as My Health Proxy

This statement indicates a need for clarification. It is not necessary to choose a family member as a health care proxy. An individual can select any trusted person, whether a family member or a friend, to act as their health care proxy. The most important factor is that the chosen person understands the individual’s wishes and is willing to advocate for them2.

Choice C reason: I Can Change Who I Designate as My Health Care Proxy at Any Time

This statement is correct. An individual can change their designated health care proxy at any time, as long as they are still capable of making their own decisions. It is important to ensure that any changes are documented properly and that all relevant parties are informed of the change3.

Choice D reason: If I Become Incapacitated, End-of-Life Choices Will Be Made by My Proxy

This statement is correct. If an individual becomes incapacitated and is unable to make their own medical decisions, the health care proxy will step in to make decisions on their behalf, including end-of-life choices. The proxy should be well-informed about the individual’s preferences and values to make decisions that align with their wishes4.

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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