A nurse is caring for a client who is receiving vancomycin by IV infusion over 30 min. Which of the following findings indicate the clien experiencing a vancomycin infusion reaction?

The client has an increased creatinine level.

The client is experiencing hypotension.

The client's IV site is red and edematous.

The c’ient reports ringing in their ears.

Answer and Explanation

The Correct Answer is B

A) The client has an increased creatinine level: While an increased creatinine level may indicate renal impairment, it is not specific to a vancomycin infusion reaction. Elevated creatinine levels may occur due to various factors, including underlying kidney disease or dehydration.

B) The client is experiencing hypotension: This is the correct answer. Hypotension, or low blood pressure, can be a manifestation of a vancomycin infusion reaction. Vancomycin infusion reactions may include anaphylaxis or anaphylactoid reactions, which can lead to systemic vasodilation and subsequent hypotension.

C) The client's IV site is red and edematous: Redness ’nd edema at the IV site may indicate phlebitis or infiltration, which are local complications rather than systemic reactions to vancomycin infusion.

D) The client reports ringing in their ears: Ringing in the ears, also known as tinnitus, is a potential side effect of vancomycin, particularly with high doses or prolonged use. However, it is not specific to a vancomycin infusion reaction and may occur independently of the infusion process.

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Correct Answer is A

Explanation

A) Elevate the extremity: This action helps reduce swelling and minimizes the spread of infiltrated fluid into surrounding tissues by using gravity to assist in draining the excess fluid back into the bloodstream. Elevating the affected limb above the level of the heart promotes venous return and can help prevent further tissue damage.

B) Flush the IV catheter: Flushing the IV catheter could exacerbate infiltration by pushing more fluid into the surrounding tissue. It is not the appropriate action for managing infiltration and could worsen the client's condition.

C) Slow the infusion rate: Slowing the infusion rate is a reasonable action to reduce the flow of fluid into the tissues and minimize further infiltration. However, it may not be sufficient to manage existing infiltration effectively or prevent tissue damage.

D) Apply pressure to the IV site: Applying pressure to the IV site is not recommended for managing infiltration. It could cause further tissue damage and discomfort for the client and is not considered a standard practice in managing this complication.

A. Insomnia B. Blurred vision C. Tachypnea D. Metallic taste

Correct Answer is B

Explanation

A) Insomnia: While insomnia can be a side effect of some medications, it is not commonly associated with carbamazepine. Therefore, it is not a priority adverse effect for the client to monitor.

B) Blurred vision: This is the correct answer. Blurred vision is a common adverse effect of carbamazepine. It can occur due to the medication's effects on the central nervous system ’nd may indicate the need for dose adjustment or further evaluation by the healthcare provider. Clients should be instructed to report any changes in vision promptly.

C) Tachypnea: Tachypnea, or rapid breathing, is not typically associated with carbamazepine use. While respiratory depression is a concern with some medications, it is not a common adverse effect of carbamazepine.

D) Metallic taste: Metallic taste is a less common adverse effect of carbamazepine. While it may occur, it is not as prevalent or significant as blurred vision, which can impact the client's daily activities and safety.

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A nurse is caring for a client who is receiving vancomycin by IV infusion over 30 min. Which of the following findings indicate the clien experiencing a vancomycin infusion reaction?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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