The nurse is caring for a patient who is receiving vancomycin (Vancocin). The nurse notes that the patient is experiencing flushing, rash, pruritus, and urticaria. The patient's heart rate is 120 beats per minute, and the blood pressure is 92/57 mm Hg. The nurse understands that these findings are consistent with:
allergic reaction.
rhabdomyolysis.
Stevens-Johnson syndrome.
red man syndrome.
The Correct Answer is D
Allergic reaction: An allergic reaction can manifest in various ways, including rash, itching, and difficulty breathing. However, the specific symptoms described, along with the context of vancomycin administration, point to red man syndrome in this case.
Rhabdomyolysis: Rhabdomyolysis is a condition where damaged muscle tissue breaks down and releases a protein called myoglobin into the bloodstream. This can cause kidney damage, but the symptoms described do not align with rhabdomyolysis.
Stevens-Johnson syndrome: Stevens-Johnson syndrome is a severe skin reaction that can cause skin and mucous membranes to blister, peel, and can be life-threatening. While it can present with rash and other skin symptoms, the symptoms mentioned in the scenario are more characteristic of red man syndrome.
Red man syndrome: As mentioned earlier, red man syndrome is an allergic reaction to vancomycin characterized by flushing, rash, pruritus, and urticaria (hives), along with rapid heart rate and low blood pressure. It is specific to vancomycin and can be prevented or minimized by slowing down the infusion rate and administering antihistamines.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. IgD: Immunoglobulin D (IgD) is found on the surface of B cells and serves as a receptor for antigen recognition during the immune response. Its exact function is not fully understood, but it plays a role in the activation of B cells.
B. IgE: Immunoglobulin E (IgE) is primarily associated with allergic responses and defense against parasitic infections. When an allergen enters the body, IgE antibodies trigger the release of histamine and other chemicals, leading to allergy symptoms. IgE is also involved in protecting against certain parasites.
C. IgG: Immunoglobulin G (IgG) is the most abundant immunoglobulin in the bloodstream. It provides long-term immunity by recognizing and neutralizing pathogens such as bacteria and viruses. IgG antibodies are involved in secondary immune responses and are transferred from mother to fetus, providing passive immunity.
D. IgM: Immunoglobulin M (IgM) is the first antibody produced during an initial immune response to an antigen. It is effective at agglutination (clumping) of pathogens. IgM antibodies are generally found in blood and lymph fluid and are the first line of defense during infections.
Correct Answer is A
Explanation
A. Discoloration of teeth: Tetracycline antibiotics can bind with calcium ions in teeth, leading to the development of yellow-gray-brown stains. This effect is particularly significant in developing teeth in children below the age of 8 and can result in permanent discoloration.
B. Anabolic change: This term doesn't specifically relate to the side effects of tetracycline. "Anabolic" generally refers to processes in the body that build up complex molecules from simpler ones. There's no direct connection between tetracycline and anabolic changes.
C. Cartilage damage: Tetracyclines, especially in high doses or with prolonged use, have been associated with potential adverse effects on cartilage. This is more relevant in individuals whose bones and cartilage are still growing, such as children. It can interfere with skeletal development.
D. Suppression of growth: Long-term use of tetracycline in children can interfere with bone growth and development. It can suppress the growth of bones and affect overall height. This is a significant concern when considering the use of tetracycline in pediatric patients.
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