A nurse is caring for a client who is mechanically ventilated and receiving propofol intravenously. Which of the following manifestations should the nurse identify as a complication of administration?

Hypokalemia

Sepsis

Urinary retention

Hypoglycemia

Answer and Explanation

The Correct Answer is B

B) Sepsis: Propofol is an intravenous sedative-hypnotic agent commonly used for sedation in mechanically ventilated patients. While propofol itself does not directly cause sepsis, its use can increase the risk of sepsis-related complications, such as infection. Propofol is typically administered intravenously, and improper handling or contamination of equipment, including intravenous lines and medication vials, can introduce pathogens into the bloodstream, leading to bloodstream infections (sepsis). Additionally, prolonged use of propofol may suppress immune function, further increasing the susceptibility to infection. Therefore, the nurse should monitor the client for signs and symptoms of sepsis, such as fever, chills, hypotension, tachycardia, and altered mental status, as a potential complication of propofol administration.

A) Hypokalemia: Hypokalemia, or low potassium levels, is not a common complication directly associated with propofol administration. While electrolyte imbalances may occur in critically ill patients, especially those receiving mechanical ventilation, hypokalemia is more likely to result from other factors such as diuretic therapy, gastrointestinal losses, or inadequate potassium intake.

C) Urinary retention: Urinary retention is not a typical complication of propofol administration. While sedative medications like propofol can affect bladder function, causing urinary retention in some cases, it is not a commonly reported complication of propofol use in mechanically ventilated patients.

D) Hypoglycemia: Hypoglycemia, or low blood sugar levels, is a potential complication of propofol administration, particularly in critically ill patients who may have altered glucose metabolism. However, hypoglycemia is not as commonly associated with propofol use as sepsis-related complications. Close monitoring of blood glucose levels is essential when administering propofol, especially if the client has preexisting diabetes mellitus or other risk factors for hypoglycemia. However, sepsis is a more direct and significant complication associated with propofol administration in mechanically ventilated patients.

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Correct Answer is B

Explanation

A) The client has an increased creatinine level: While an increased creatinine level may indicate renal impairment, it is not specific to a vancomycin infusion reaction. Elevated creatinine levels may occur due to various factors, including underlying kidney disease or dehydration.

B) The client is experiencing hypotension: This is the correct answer. Hypotension, or low blood pressure, can be a manifestation of a vancomycin infusion reaction. Vancomycin infusion reactions may include anaphylaxis or anaphylactoid reactions, which can lead to systemic vasodilation and subsequent hypotension.

C) The client's IV site is red and edematous: Redness ’nd edema at the IV site may indicate phlebitis or infiltration, which are local complications rather than systemic reactions to vancomycin infusion.

D) The client reports ringing in their ears: Ringing in the ears, also known as tinnitus, is a potential side effect of vancomycin, particularly with high doses or prolonged use. However, it is not specific to a vancomycin infusion reaction and may occur independently of the infusion process.

A. Ask another nurse if they are aware of potential interactions. B. Check the client's medical record for medication and food’interactions. C. Consult a drug reference guide for possible interactions. D. Have the client take the medication on an empty stomach to avoid interactions.

Correct Answer is C

Explanation

A) Ask another nurse if they are aware of potential interactions: Relying solely on another nurse's awareness of potential interactions is’not a comprehensive or reliable approach. Nurses may have varying levels of knowledge about medication interactions, and it's important to consult verified sources ’or accurate information.

B) Check the client's medical record for medication and food’interactions: While the client's medical record may contain information’about their current medications, it may not provide detailed information about potential interactions with specific foods or other medications. Additionally, relying solely on the medical record may not capture recent changes in medication or dietary intake.

C) Consult a drug reference guide for possible interactions: This is the correct action. Drug reference guides provide comprehensive information about medications, including potential interactions with other drugs and food. Nurses can access reliable drug reference guides to ensure they have accurate information before administering medications.

D) Have the client take the medication on an empty stomach to avoid interactions: Instructing the client to take medication on an empty stomach without knowledge of specific interactions could be inappropriate and potentially harmful. Some medications require administration with food to enhance absorption or reduce gastrointestinal side effects. It's essential to consult reliable sources ’o determine the appropriate administration instructions for each medication.

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A nurse is caring for a client who is mechanically ventilated and receiving propofol intravenously. Which of the following manifestations should the nurse identify as a complication of administration?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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