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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
A balanced diet that includes fruits and vegetables is important for overall health, but it is not specifically related to the timing of sexual intercourse for conception.
Choice B rationale:
Using a lubricant during sexual intercourse can sometimes interfere with sperm motility and decrease the chances of conception.
Choice C rationale:
Having sexual intercourse 2 days following ovulation can increase the chances of fertilization since sperm can survive in the female reproductive tract for several days, and the egg is viable for a shorter period.
Choice D rationale:
While the type of underwear worn by the partner can influence testicular temperature, there is limited evidence to support the claim that tight-fitting underwear significantly affects fertility.
Correct Answer is D
Explanation
Choice A rationale:
Rapid mood swings are not a defining characteristic of major depressive disorder.
Choice B rationale:
Hearing voices is a symptom more commonly associated with conditions like schizophrenia.
Choice C rationale:
Expressing mistrust of the nurse is not a specific symptom of major depressive disorder.
Choice D rationale:
A hallmark symptom of major depressive disorder is anhedonia, which is the diminished ability to experience pleasure or interest in previously enjoyed activities.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.