Practice Question
Patient Data.
Answer Choices:
Rationale:
Skin color
🔹 The client’s skin remains red despite improvement in other vital signs, which is a residual manifestation of the ongoing adverse reaction to vancomycin.
🔹 Skin flushing and erythema are hallmark findings in infusion-related reactions like red man syndrome, even after initial treatment.
🔹 This persistent skin change indicates that the histamine-mediated vascular response is still active, though less severe.
Increased heart rate
🔹 Although the heart rate improved from 110 bpm to 90 bpm and then to 60 bpm, any episode of tachycardia during the reaction is a sign of systemic involvement.
🔹 The earlier elevated heart rate reflects the body’s compensatory response to vasodilation and hypotension.
🔹 Monitoring heart rate trends is crucial because a recurrence or rebound in tachycardia could signal worsening of the reaction.
Dyspnea
🔹 Even though it is not directly stated that the client is currently breathless, dyspnea is a possible ongoing symptom in systemic hypersensitivity due to histamine-induced bronchoconstriction or airway involvement.
🔹 Continued respiratory monitoring is essential because airway compromise can develop later in the reaction, especially if it progresses toward anaphylaxis.
🔹 Early identification allows for prompt intervention with oxygen therapy, bronchodilators, or escalation to advanced airway management.
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This question is from HESI-RN Pharmacology with NGN-2025 which contains 58 questions.
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Patient Data.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: HESI Exam(s)
- Domain: Hesi Pharmacology
- Answer Choices: 0