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:

Placing the newborn under a radiant warmer is not directly related to addressing breastfeeding-related jaundice.

Choice B rationale:

Supplementing breastfeeding with formula is not the first-line approach and may interfere with establishing successful breastfeeding.

Choice C rationale:

Breastfeeding-related jaundice can occur if the newborn is not effectively breastfeeding and not getting enough milk. Assessing the effectiveness of breastfeeding is important to address the underlying cause of jaundice.

Choice D rationale:

Administering Rho(D) immune globulin is unrelated to addressing jaundice in a breastfed newborn.

A. 15 mL of drainage in Hemovac B. Periorbital ecchymosis C. Nonreactive pupils D. Hgb 11 g/dL

Correct Answer is C

Explanation

Choice A rationale:

Drainage in the Hemovac is an expected finding postoperatively and is not as urgent as nonreactive pupils.

Choice B rationale:

Periorbital ecchymosis (bruising around the eyes) is not uncommon after a craniotomy and is not as urgent as nonreactive pupils.

Choice C rationale:

Nonreactive pupils can indicate a neurological emergency, such as increased intracranial pressure or potential damage to the cranial nerves. This finding requires immediate attention to prevent further complications.

Choice D rationale:

Hemoglobin level of 11 g/dL is within a normal range and is not a priority concern.

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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

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