The nurse is caring for a client who is receiving vancomycin. The nurse notes the client is experiencing flushing, rash, pruritus, and urticaria. The client's heart rate is 120 beats/min, and blood pressure is 92/57 mm Hg. What complication is the client experiencing?

Rhabdomyolysis

Red man syndrome

Side effects

Stevens-Johnson syndrome

Answer and Explanation

The Correct Answer is B

A) Rhabdomyolysis is a serious condition characterized by the breakdown of skeletal muscle tissue and is not associated with the symptoms described.

B) Red man syndrome is an infusion reaction associated with the rapid infusion of vancomycin. Symptoms include flushing, rash, pruritus, urticaria, tachycardia, and hypotension.

C) Side effects are general and can include a range of symptoms. Red man syndrome is a specific reaction associated with vancomycin.

D) Stevens-Johnson syndrome is a severe skin reaction that involves blistering and peeling of the skin. It is not associated with the rapid infusion of vancomycin.

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Correct Answer is B

Explanation

a) Concurrent use of acetaminophen is not directly related to heparin therapy for atrial fibrillation. It may need attention but does not warrant immediate reporting.

b) An aPTT of 80 seconds is significantly prolonged and may indicate a risk of bleeding due to excessive anticoagulation. This finding requires immediate notification to the healthcare provider.

c) An INR of 0.8 is within the normal range and does not pose an immediate concern in the context of heparin infusion.

d) Dark, tarry stools could indicate gastrointestinal bleeding but may not be directly related to heparin therapy. It sho

A. Drowsiness B. Constipation C. Oliguria D. Tachycardia

Correct Answer is A

Explanation

a) Theophylline, a bronchodilator, can cause central nervous system stimulation, leading to side effects such as insomnia, nervousness, and drowsiness.

b) Constipation is not a common adverse effect of theophylline.

c) Oliguria is not a typical side effect of theophylline.

d) Tachycardia is more commonly associated with theophylline toxicity. While it can be a side effect, it is not the most prominent or common adverse effect.

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The nurse is caring for a client who is receiving vancomycin. The nurse notes the client is experiencing flushing, rash, pruritus, and urticaria. The client's heart rate is 120 beats/min, and blood pressure is 92/57 mm Hg. What complication is the client experiencing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a new diagnosis of atrial fibrillation is receiving a continuous infusion of heparin. Which finding will the nurse report immediately?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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