The nurse is assisting in the administration of IV vancomycin to a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following findings indicate an allergic reaction to the medication?

Hypertension

Headache

Tinnitus

Urticaria

Answer and Explanation

The Correct Answer is D

Rationale:

A. Hypertension: Hypertension is not typically associated with an allergic reaction to vancomycin. Hypotension may occur in severe reactions like "red man syndrome," but elevated blood pressure is generally unrelated to allergic responses.

B. Headache: Headache is a possible side effect of many medications, including vancomycin, but it does not specifically indicate an allergic reaction. It is a nonspecific symptom and usually does not warrant discontinuation unless severe.

C. Tinnitus: Tinnitus is a sign of ototoxicity, a known adverse effect of vancomycin, especially with high doses or prolonged use. However, it is not indicative of an allergic reaction but rather toxicity affecting the auditory system.

D. Urticaria: Urticaria, or hives, is a classic manifestation of an allergic reaction involving histamine release causing itchy, raised, red skin lesions. Its presence during vancomycin administration signals hypersensitivity and requires immediate attention.

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Correct Answer is B

Explanation

Rationale:

A. Apply a warm compress: Applying a warm compress may help promote absorption of infiltrated fluid and reduce discomfort, but it should not be the initial action. Warm compresses are appropriate only after the infusion is stopped and proper assessment is completed.

B. Stop the infusion: The first priority when infiltration is suspected—evidenced by cool, edematous skin—is to stop the infusion immediately. Continuing the infusion could lead to worsening tissue damage or complications depending on the type of fluid or medication.

C. Document the infiltration: Documentation is necessary but not the immediate priority. It should follow prompt clinical action to stop the infusion and prevent further harm to the surrounding tissue.

D. Elevate the arm: Elevating the arm can help reduce edema, but this supportive measure should be done only after the infusion has been stopped. It does not address the root cause or prevent further infiltration.

A. Wipe from the outer to the inner canthus after administering the crops. B. Position the child side-lying on the bed before administering the drops. C. Apply pressure to the lacrimal punctum after administering the drops. D. Flush the eye with formal saline solution before administering the drops.

Correct Answer is C

Explanation

Rationale:

A. Wipe from the outer to the inner canthus after administering the drops: The correct technique is to wipe from the inner to the outer canthus to avoid introducing pathogens into the lacrimal system. Wiping in the wrong direction increases the risk of eye infections.

B. Position the child side-lying on the bed before administering the drops: Eye drops should be administered with the child in a supine or slightly reclined position. Side-lying positioning is more appropriate for ear drops and does not allow proper exposure of the conjunctival sac.

C. Apply pressure to the lacrimal punctum after administering the drops: Pressing the lacrimal punctum (inner corner of the eye) helps prevent systemic absorption of the medication by occluding the tear duct. This increases local efficacy and reduces the risk of systemic side effects, which is especially important in children.

D. Flush the eye with formal saline solution before administering the drops: Flushing with formal saline is unnecessary unless there is debris or discharge. Routine eye drop administration does not require pre-flushing..

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The nurse is assisting in the administration of IV vancomycin to a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following findings indicate an allergic reaction to the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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