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 C

Explanation

Choice A rationale:

Asterixis is a hand-flapping tremor that can be associated with hepatic encephalopathy, not pancreatic cancer.

Choice B rationale:

Weight gain is not typically associated with pancreatic cancer and may not be a relevant manifestation to include.

Choice C rationale:

Abdominal pain is a common manifestation of pancreatic cancer and should be included in the teaching.

Choice D rationale:

Constipation is not typically associated with pancreatic cancer and may not be a relevant manifestation to include.

A. Initiate a high-protein diet for the client. B. Encourage the client to eat high-fiber foods. C. Administer laxatives to the client PRN daily. D. Provide the client with six small meals per day.

Correct Answer is B

Explanation

Choice A rationale:

A high-protein diet might not be recommended for a client with chronic pancreatitis, as certain high-protein foods can exacerbate symptoms.

Choice B Rationale:

Encouraging the client to eat high-fiber foods can help manage symptoms of chronic pancreatitis, as well as promote regular bowel movements and prevent constipation.

Choice C rationale:

Administering laxatives daily is not typically part of the management plan for chronic pancreatitis and can lead to dependency.

Choice D rationale:

Providing six small meals per day might be helpful, but the specific dietary content is important for managing chronic pancreatitis.

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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

A nurse is teaching a client who has a family history of pancreatic cancer about manifestations associated with the disease. Which of the following findings should the nurse include?

Correct Answer is C

Explanation

A nurse is planning care for a client who has chronic pancreatitis. Which of the following interventions should the nurse include in the plan?

Correct Answer is B

Explanation

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