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:
Sparse eyelashes are a common physical characteristic of individuals with Down syndrome and do not typically require immediate notification of the provider.
Choice B rationale:
Cracked skin on feet is not uncommon, and while it may need attention, it does not generally require immediate notification of the provider.
Choice C rationale:
Persistent neck pain in a child with Down syndrome could indicate an underlying issue and should be reported for further evaluation.
Choice D rationale:
Hyperflexibility is a common feature of Down syndrome and does not typically require immediate notification of the provider.
Correct Answer is A
Explanation
Choice A rationale:
Clomiphene is used to induce ovulation in women with infertility. Hot flashes are a common side effect of clomiphene due to its impact on hormone levels. Clomiphene is a medication that stimulates ovulation by blocking estrogen receptors in the hypothalamus and pituitary gland. This causes an increase in the production of follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which stimulate the growth and maturation of ovarian follicles. One of the common side effects of clomiphene is hot flashes, which are caused by the sudden drop in estrogen levels. Hot flashes can be mild or severe, and can occur at any time of the day or night. They usually last for a few minutes and can be accompanied by sweating, palpitations, anxiety, or nausea.
Choice B rationale:
Changes in taste are not a typical side effect of clomiphene.
Choice C rationale:
A dry cough is not typically associated with clomiphene.
Choice D rationale:
Migraine with aura is not typically associated with clomiphene.
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