A male client has been receiving the antibiotic gentamicin sulfate IV piggyback every 12 hours for several days. Which observations by the nurse indicate that the client may be experiencing an adverse effect of gentamicin?

Anaphylaxis is a severe and potentially life-threatening allergic reaction that occurs rapidly after exposure to an allergen. The symptoms of anaphylaxis can vary but usually involve multiple organ systems, including the skin, respiratory, cardiovascular, and gastrointestinal systems.

Wheezing and dyspnea are two common symptoms of anaphylaxis that indicate the respiratory system's involvement.

Urticaria and pruritis are skin manifestations that can also be present in anaphylaxis, but they are not specific to this condition.

Insomnia and irritability are not typical symptoms of anaphylaxis.

Tinnitus and diplopia are also not common symptoms of anaphylaxis.

The correct answer is C. Instruct the client to request assistance when ambulating to the bathroom.

Choice A reason:

Advise the client that the medication should start to work in about 30 minutes.

While it is important to inform the client about the onset of action of the medication, this is not the highest priority. Codeine, an opioid, can cause dizziness and sedation, which increases the risk of falls. Therefore, safety measures take precedence over informing the client about the medication’s onset time.

Choice B reason:

Administer a stool softener/laxative at the same time as the analgesic.

Opioids like codeine can cause constipation, so administering a stool softener or laxative is a good practice. However, this action is not the highest priority when considering the immediate safety of the client. Ensuring the client’s safety from potential falls due to dizziness or sedation is more urgent.

Choice C reason:

Instruct the client to request assistance when ambulating to the bathroom.

This is the correct answer because codeine can cause dizziness, sedation, and orthostatic hypotension, increasing the risk of falls. Ensuring the client requests assistance when moving can prevent potential injuries, making it the highest priority nursing action.

Choice D reason:

Tell the client to notify the nurse if the pain is not relieved.

While it is important for the client to communicate about the effectiveness of pain relief, this is not the highest priority. The immediate concern is the client’s safety due to the sedative effects of codeine. Therefore, preventing falls and injuries takes precedence.