A nurse is evaluating a client's response after initiating an intermittent IV bolus of vancomycin. Which of the following findings indicates the client is experiencing an allergic reaction to the medication?
Hypertension
Dyspnea
Tetany
Headache
The Correct Answer is B
A. Hypertension: An allergic reaction to vancomycin typically does not cause high blood pressure. Blood pressure changes may occur with severe reactions, but hypertension is not a primary indicator.
B. Dyspnea: Difficulty breathing indicates a hypersensitivity or allergic reaction to vancomycin. Respiratory distress, along with potential hypotension, rash, or urticaria, signals the need for immediate intervention.
C. Tetany: Tetany is related to hypocalcemia or electrolyte imbalances, not vancomycin allergy. It is not an expected manifestation of an allergic response.
D. Headache: Headache is a nonspecific symptom and is not characteristic of an allergic reaction to vancomycin. It does not reliably indicate hypersensitivity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Thyroid-stimulating hormone level: TSH levels are used to assess thyroid function and are not affected by vancomycin therapy. Monitoring TSH is unrelated to safe administration of this antibiotic.
B. Blood glucose level: Blood glucose monitoring is important for clients with diabetes or receiving medications that affect glucose, but it is not directly relevant to vancomycin dosing or toxicity.
C. Total iron-binding count: Total iron-binding capacity reflects iron status and is unrelated to vancomycin therapy. It does not influence dosing or safety considerations for this antibiotic.
D. BUN level: Vancomycin is nephrotoxic, and kidney function must be monitored to prevent accumulation and toxicity. Blood urea nitrogen (BUN) provides an indicator of renal function, and reviewing it prior to the next dose helps ensure safe administration.
Correct Answer is D
Explanation
A. "Take the medication with an antacid if you have gastric distress.": Antacids can interfere with the absorption of phenytoin, reducing its effectiveness. It is not recommended to take phenytoin simultaneously with antacids.
B. "Dissolve the capsules in water prior to taking the medication.": Extended-release phenytoin capsules should be swallowed whole to maintain the time-release mechanism. Crushing or dissolving the capsules can cause rapid absorption and increase the risk of toxicity.
C. "Discontinue the medication if you experience a seizure.": Phenytoin should not be stopped abruptly, even if seizures occur, as this can precipitate status epilepticus. Any dosage concerns should be discussed with the healthcare provider before making changes.
D. "Use a soft-bristled toothbrush to brush your teeth.": Phenytoin can cause gingival hyperplasia, leading to swollen and bleeding gums. Using a soft-bristled toothbrush and practicing good oral hygiene helps minimize gum irritation and maintain oral health.
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