ATI Capstone Exam 2 Final | Nurselytic

Questions 116

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ATI Capstone Exam 2 Final Questions

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Question 1 of 5

A nurse is assessing a client who is receiving IV vancomycin. The nurse notes a flushing of the neck and tachycardia. Which of the following actions should the nurse take?

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Correct Answer: A

Rationale: The correct answer is A: Decrease the infusion rate. Flushing of the neck and tachycardia are signs of red man syndrome, a common adverse reaction to vancomycin. Decreasing the infusion rate can help minimize the severity of the reaction. Changing the IV site or applying cold compresses are not appropriate interventions for this specific reaction. Documenting an anaphylactic reaction without confirmation is premature and can lead to misinformation in the client's medical record.

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Question 5 of 5

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