A nurse is caring for a client receiving IV vancomycin. The nurse notes flushing of the client's neck and chest. Which of the following actions should the nurse take?

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ATI Capstone Pharmacology Assessment 1 Questions

Question 1 of 5

A nurse is caring for a client receiving IV vancomycin. The nurse notes flushing of the client's neck and chest. Which of the following actions should the nurse take?

Correct Answer: C

Rationale: The correct action for the nurse to take when a client receiving IV vancomycin shows flushing of the neck and chest is to slow the infusion rate. Flushing is a common sign of Red Man Syndrome, which is associated with rapid infusions of vancomycin. Slowing down the infusion rate can help prevent further flushing and the development of Red Man Syndrome. Stopping the infusion (Choice A) may be too drastic if the symptoms are mild and can be managed by slowing the rate. Documenting the findings as a harmless reaction (Choice B) is incorrect because flushing should be addressed promptly to prevent complications. Administering diphenhydramine (Choice D) is not the initial or best intervention for flushing associated with vancomycin; slowing the infusion rate is the priority.

Question 2 of 5

A nurse is providing client education regarding lithium therapy. Which of the following instructions should the nurse include?

Correct Answer: B

Rationale: The correct answer is B. The nurse should instruct the client to avoid excessive intake of caffeinated beverages as they can interfere with lithium levels. Option A is incorrect as lithium is usually recommended to be taken on an empty stomach. Option C is not directly related to lithium therapy. Option D is not a typical instruction for lithium therapy.

Question 3 of 5

A client is receiving magnesium sulfate for the management of preeclampsia. Which of the following client assessments should the nurse monitor to prevent complications of therapy?

Correct Answer: B

Rationale: The correct answer is deep tendon reflexes. Monitoring deep tendon reflexes is crucial to assess for magnesium toxicity during therapy for preeclampsia. Magnesium sulfate can lead to neuromuscular blockade, reflected by decreased or absent deep tendon reflexes. Assessing bowel sounds (choice A) is important for gastrointestinal function but is not directly related to magnesium sulfate therapy. Oxygen saturation (choice C) is vital for respiratory status but is not specifically linked to magnesium sulfate administration. Fluid balance (choice D) is essential but does not directly correlate with monitoring for complications of magnesium sulfate therapy in the context of preeclampsia.

Question 4 of 5

A nurse is caring for a client who is prescribed warfarin. Which of the following laboratory tests should the nurse review to evaluate the therapeutic effect of this medication?

Correct Answer: B

Rationale: The correct answer is B: INR. The International Normalized Ratio (INR) is the most reliable test for evaluating the therapeutic effects of warfarin therapy. INR measures the clotting ability of the blood and helps determine if the dosage of warfarin is within the therapeutic range. Choice A, aPTT, is not typically used to monitor the effects of warfarin. Choice C, Serum glucose, and choice D, Bilirubin, are not relevant to monitoring the therapeutic effect of warfarin.

Question 5 of 5

A nurse is caring for a client with hypothyroidism. Which of the following findings indicates that the client is experiencing an adverse effect from the prescribed levothyroxine?

Correct Answer: A

Rationale: Tachycardia is the correct answer as it is an adverse effect of levothyroxine. Levothyroxine is a medication used to treat hypothyroidism by supplementing the body with thyroid hormone. Tachycardia, or a fast heart rate, can indicate an overdosage or increased sensitivity to levothyroxine. Bradycardia, slow heart rate, weight loss, and increased appetite are not typically associated with adverse effects of levothyroxine. Bradycardia may actually be a symptom of untreated hypothyroidism.

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