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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Constipation is not typically associated with hyperthyroidism. Hyperthyroidism usually speeds up the body’s metabolism, leading to symptoms like increased bowel movements or diarrhea rather than constipation.
Choice B Reason:
Sensitivity to cold is more commonly associated with hypothyroidism, where the body’s metabolism slows down. In hyperthyroidism, patients often experience heat intolerance due to an increased metabolic rate.
Choice C Reason:
Weight gain of 4.5 kg (10 lbs) in 3 weeks is also more indicative of hypothyroidism. Hyperthyroidism generally causes weight loss despite an increased appetite because of the accelerated metabolism.
Choice D Reason:
Frequent mood changes are a common symptom of hyperthyroidism. The excess thyroid hormones can affect the nervous system, leading to symptoms such as anxiety, irritability, and mood swings.
Correct Answer is B
Explanation
Choice A reason: Take naproxen for generalized discomfort
Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that can help with generalized discomfort. However, NSAIDs can cause fluid retention and worsen heart failure symptoms. They can also increase the risk of kidney damage and gastrointestinal bleeding, especially in individuals with heart failure. Therefore, it is generally advised to avoid NSAIDs and use alternative pain relief methods, such as acetaminophen, under the guidance of a healthcare provider.
Choice B reason: Notify the provider of a weight gain of 0.5 kg (1 lb) in a week
Monitoring weight is crucial for individuals with heart failure, as sudden weight gain can indicate fluid retention and worsening heart failure. A weight gain of 0.5 kg (1 lb) in a week is significant and should be reported to the healthcare provider immediately. This allows for timely intervention to adjust medications or other treatments to prevent further complications. Regular weight monitoring helps in early detection of fluid buildup and effective management of heart failure.
Choice C reason: Take diuretics early in the morning and before bedtime
Diuretics are commonly prescribed to help reduce fluid buildup in individuals with heart failure. However, taking diuretics before bedtime can lead to frequent nighttime urination, disrupting sleep. It is generally recommended to take diuretics early in the morning to minimize this issue. If a second dose is needed, it should be taken in the early afternoon to avoid nighttime disturbances.
Choice D reason: Exercise at least three times per week
Regular exercise is beneficial for individuals with heart failure as it helps improve cardiovascular health, increase stamina, and reduce symptoms. However, the exercise regimen should be tailored to the individual’s condition and capabilities. It is important to consult with a healthcare provider to develop a safe and effective exercise plan. Cardiac rehabilitation programs can also provide structured exercise guidance and support.
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