How it Works
Try Naxlex NCLEX-RN (Free-Trial)

A nurse is caring for a client on a medical-surgical unit. Complete the following sentence by using the lists of options.

Exhibits

The nurse should first

due to the client’s .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Rationale for Correct Choices:

  • Stop the IV infusion: The client is showing signs of a severe allergic reaction, including flushing, generalized itching, hypotension, tachycardia, hypoxia, and difficulty breathing shortly after vancomycin administration. Immediate cessation of the infusion is critical to prevent progression of anaphylaxis.
  • Anaphylaxis: The client is exhibiting the classic signs of an anaphylactic-type reaction. The rapid infusion rate (325 mL/hr) is very high for Vancomycin and often causes Red Man Syndrome, which is a histamine release reaction. However, the presence of difficulty breathing elevates this to anaphylactic or severe hypersensitivity reaction, requiring the most urgent response.

Rationale for Incorrect Choices:

  • Administer epinephrine: Epinephrine is the first-line treatment for anaphylaxis, but it is administered after stopping the offending agent. Halting the infusion is the initial, priority nursing action.
  • Request a serum peak drug level: Monitoring vancomycin peak or trough levels is important for toxicity prevention, but it is not the immediate priority during an acute hypersensitivity reaction.
  • Nephrotoxicity: Elevated WBC or vancomycin trough does not indicate acute nephrotoxicity here, and the patient’s acute symptoms are consistent with an allergic reaction rather than kidney injury.
  • Sepsis: Although the client has cellulitis and elevated WBCs, the sudden onset of hypotension, flushing, and respiratory distress after IV antibiotic administration is more indicative of anaphylaxis rather than sepsis.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is B

Explanation

A. Take the medication in the morning: Simvastatin is more effective when taken in the evening because cholesterol synthesis is higher at night. Taking it in the morning may reduce its lipid-lowering effect.

B. Report muscle tenderness: Muscle pain, tenderness, or weakness can indicate myopathy or rhabdomyolysis, serious adverse effects of statins. Clients should report these symptoms promptly for evaluation and possible medication adjustment.

C. This medication can cause kidney damage: Simvastatin primarily affects the liver and muscles. While rhabdomyolysis can indirectly impact kidney function, kidney damage is not a common direct effect of the medication.

D. Avoid drinking grapefruit juice for 3 hr after taking this medication: Grapefruit juice can inhibit metabolism of simvastatin, increasing the risk of toxicity. Avoiding grapefruit entirely, rather than timing it around the dose, is the recommended precaution.

Correct Answer is C

Explanation

A. Check the client's pulse oximetry level every 6 hr: Pulse oximetry provides valuable information on oxygen saturation, but checking only every 6 hours may not detect early respiratory depression caused by opioid PCA therapy.

B. Check the client's blood pressure every 4 hr: Blood pressure monitoring is important postoperatively, but opioid-induced respiratory depression is a more immediate risk in the first 24 hours of PCA use, so respirations take priority.

C. Check the client's respirations every 2 hr: Opioids administered via PCA can cause respiratory depression, especially in the first 24 hours. Monitoring respiratory rate frequently allows for early detection and intervention if hypoventilation occurs.

D. Assess the client's apical heart rate every 8 hr: While cardiac monitoring may be indicated for some clients, the apical heart rate is not the most critical assessment for PCA therapy. Respiratory function is the priority for detecting opioid-related complications.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register