A nurse is caring for a client who is receiving an initial dose of vancomycin IV. The client begins experiencing dyspnea and swelling of the face. After discontinuing the vancomycin infusion, which of the following actions should the nurse take next?

Call the rapid response team.

Prepare the client for intubation.

Obtain an ABG level.

Administer diphenhydramine.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The client is experiencing signs of an allergic reaction or anaphylaxis, which can be life-threatening. The rapid response team should be called to provide immediate medical assistance.

Choice B rationale:

Intubation is not the immediate priority. Addressing the allergic reaction and ensuring the client's airway, breathing, and circulation are the first steps.

Choice C rationale:

Obtaining an arterial blood gas (ABG) level is not the priority when the client is experiencing respiratory distress and facial swelling.

Choice D rationale:

Administering diphenhydramine may be part of the treatment plan, but the immediate priority is to call for emergency assistance to manage the allergic reaction.

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Correct Answer is A

Explanation

Choice A rationale:

Infants with osteogenesis imperfecta have fragile bones that can fracture easily. Using pillows or other soft support can help prevent accidental fractures during diaper changes.

Choice B rationale:

Immunizations are important for all infants and should not be withheld, even in the presence of osteogenesis imperfecta.

Choice C rationale:

Blood pressure measurement is not a common concern in infants with osteogenesis imperfecta.

Choice D rationale:

Splints may be used to provide support for the infant's limbs to minimize the risk of fractures.

A. "You will need to have your blood drawn every 2 weeks." B. "You will self-administer one dose intramuscularly each day." C. "This medication is safe to take if you become pregnant. D. "You should limit your daily fluid intake to 1 and a half liters."

Correct Answer is A

No explanation

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A nurse is caring for a client who is receiving an initial dose of vancomycin IV. The client begins experiencing dyspnea and swelling of the face. After discontinuing the vancomycin infusion, which of the following actions should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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