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 D

Explanation

D) Oxycodone causes central nervous system depression: Oxycodone is an opioid analgesic that acts centrally on the central nervous system (CNS) to relieve pain. One of the most significant side effects of opioids like oxycodone is respiratory depression, which occurs due to the suppression of the CNS, particularly in the brainstem respiratory centers. The brainstem regulates respiratory rate and rhythm, and when opioids depress these centers, it can lead to decreased respiratory drive, resulting in a decrease in respiratory rate. A respiratory rate of 8/min is significantly below the normal range, indicating respiratory depression caused by oxycodone.

A) Oxycodone inhibits prostaglandin synthesis: Oxycodone does not directly inhibit prostaglandin synthesis. Prostaglandins are lipid compounds with various physiological effects, including inflammation and pain modulation. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, inhibit prostaglandin synthesis by blocking cyclooxygenase enzymes. However, oxycodone primarily acts on opioid receptors in the CNS to relieve pain, rather than through prostaglandin inhibition.

B) Oxycodone promotes vasodilation of cranial arteries: While opioids can cause peripheral vasodilation, particularly in large doses, the primary mechanism of action of oxycodone is not through the promotion of vasodilation of cranial arteries. Vasodilation may occur as a side effect of opioid use, but it is not the primary cause of respiratory depression associated with oxycodone.

C) Oxycodone blocks the sodium channel suspending nerve conduction: This statement describes the mechanism of action of local anesthetics, such as lidocaine, which block sodium channels to inhibit nerve conduction. However, oxycodone is not a sodium channel blocker. Its analgesic effects result from binding to opioid receptors in the CNS, particularly mu-opioid receptors, rather than blocking sodium channels. Therefore, this option is not the pathophysiology for the respiratory rate of 8/min observed in the client receiving oxycodone.

A. Black stools B. Dry cough C. Oral candidias D. Tardive dyskinesia

Correct Answer is D

Explanation

A) Black stools: While black stools can be a potential side effect of gastrointestinal bleeding, it is not commonly associated with high-dose metoclopramide. This side effect is more commonly seen with medications such as aspirin or NSAIDs. Therefore, it is not the most pertinent adverse effect to monitor for with high-dose metoclopramide.

B) Dry cough: Dry cough is not a typical adverse effect of metoclopramide. Cough is more commonly associated with medications such as ACE inhibitors. Therefore, it is not the primary adverse effect to monitor for with high-dose metoclopramide.

C) Oral candidiasis: While oral candidiasis (oral thrush) can occur as a side effect of some medications, it is not commonly associated with metoclopramide. Oral candidiasis is more frequently seen with corticosteroids or antibiotics. Therefore, it is not the primary adverse effect to monitor for with high-dose metoclopramide.

D) Tardive dyskinesia: Tardive dyskinesia is a serious adverse effect associated with prolonged use of edicaopramide, especially at high doses. It is characterized by involuntary, repetitive movements of the face, tongue, or other parts of the body. Monitoring for signs and symptoms of tardive dyskinesia, such as repetitive facial grimacing or tongue protrusion, is crucial when administering high-dose metoclopramide to prevent this potentially irreversible condition. Therefore, this is the correct adverse effect to monitor for in clients receiving high-dose metoclopramide.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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