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 B

Explanation

A) Ex edicationr bubble from the syringe prior to administering the medication: Expelling air bubbles is necessary when administering medications via intravenous injection to prevent air embolisms. However, with subcutaneous injections like enoxaparin, the presence of small air bubbles is not usually a concern, and expelling them is not necessary.

B) Administer the medication into the anterolateral or posterolateral abdominal area: This is the correct action for administering enoxaparin. Enoxaparin is typically administered subcutaneously into the anterolateral or posterolateral abdominal wall. This site is preferred due to its high vascularity and good absorption of the medication.

C) Hold the skin taut at the injection site while administering the medication: While holding the skin taut can help reduce discomfort during the injection, it is not always necessary. The choice to hold the skin taut depends on the client's body habitus and the nurse's preferenc’. It is not a specific requi’ement for administering enoxaparin.

D) Massage the injection site after administering the medication: Massaging the injection site after administering enoxaparin is not recommended. It can increase bruising or bleeding at the injection site. Instead, after administering the medication, the nurse should apply gentle pressure with a dry cotton ball or gauze pad to help minimize bleeding.

A. Lactated Ringer's B. Dextrose 10% in water C. 0.45% sodi’m chloride D. 0.9% sodium chloride

Correct Answer is B

Explanation

A) Lactated Ringer's: Lactated Ringer's solution is not app’opriate in this si’uation because it does not provide the necessary nutrients found in TPN. It is primarily used for fluid replacement and maintenance and does not contain the essential macronutrients required for TPN.

B) Dextrose 10% in water: This is the correct fluid to administer when the current bag of TPN has finished infusing and the next bag is not yet available. Dextrose 10% in water provides a source of glucose, which can help prevent hypoglycemia in clients dependent on TPN. While it does not provide the full spectrum of nutrients found in TPN, it can temporarily meet the client's caloric needs until the next bag of TP’ becomes available.

C) 0.45% sodium chloride: This solution, also known as half-normal saline, is hypotonic and primarily used for hydration and maintenance fluids. It does not provide adequate nutrition and is not a suitable substitute for TPN.

D) 0.9% sodium chloride: This solution, also known as normal saline, is isotonic and used for fluid resuscitation, maintenance, and replacement. Like 0.45% sodium chloride, it does not contain the necessary nutrients for TPN and is not appropriate as a substitute.

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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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