A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is initiated. In which, order should the nurse implement these interventions? (Arrange the actions in order of priority, with the highest priority first, and the least priority last or at the bottom.)
Stop the Infusion.
Assess vital signs
Contact the healthcare provider.
Initiate an adverse event report.
Document reaction to the drug.
The Correct Answer is A,B,C,D,E
A) This is because the client is experiencing an allergic reaction to piperacillin, which can be life-threatening. The nurse should stop the infusion immediately to prevent further exposure to the drug and assess vital signs to monitor for signs of anaphylaxis, such as hypotension, tachycardia, wheezes, or stridor.
B) Assessing vital signs is a priority to determine the severity of the reaction and the client's overall condition.
C) The nurse should contact the healthcare provider to report the situation and obtain orders for treatment, such as antihistamines, corticosteroids, or epinephrine.
D) The nurse should initiate an adverse event report to document the incident and follow the facility's protocol for reporting medication errors.
E) The nurse should also document the reaction to the drug in the client's chart and notify the pharmacy to avoid future administration of piperacillin or related antibiotics.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Assessing the client's level of consciousness involves observing their responsiveness, orientation, and ability to follow commands. If the client is unresponsive or exhibits any signs of altered consciousness, the nurse should immediately activate the emergency response system and begin resuscitative measures, such as administering oxygen and initiating cardiopulmonary resuscitation (CPR) if necessary.
Once the client's level of consciousness is established and the emergency response system has been activated if necessary, the nurse can proceed to assess the depth of the slashes, estimate the amount of blood loss, and find the object used to cause the injuries. These assessments will provide important information about the extent and severity of the client's injuries, which will guide subsequent interventions.
Correct Answer is C
Explanation
A) Incorrect- The left lateral position might not provide enough lung expansion for a client in respiratory distress.
B) Incorrect- Reverse Trendelenburg (head of bed elevated, foot of bed lowered) might not provide enough lung expansion and could exacerbate respiratory distress.
C) Correct- The High-Fowler's position, where the client is sitting upright at a 90-degree angle or as upright as tolerated, helps to improve lung expansion, reduce pressure on the diaphragm, and promote optimal oxygenation. This position is commonly used for clients with respiratory distress.
D) Incorrect- The supine position may worsen pulmonary congestion and compromise lung expansion in clients with pulmonary edema.
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