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A nurse is assisting with the care of a client.

  • At 1600, the nurse administered an antibiotic as prescribed.
  • At 1630, the nurse noted that the client’s bilateral breath sounds were clear and present throughout.
  • The client reports itching on the chest and has urticaria over the chest and trunk.
  • The client states they are having difficulty swallowing and feel as if there is a lump in their throat.
  • The nurse hears bilateral breath sounds with scattered wheezing throughout.

What should the nurse do next?

A.

Stop the antibiotic infusion immediately and notify the healthcare provider.

B.

Apply a cool compress to the itchy areas and monitor for further reactions.

C.

Administer diphenhydramine (Benadryl) as a first-line treatment.

D.

Assess the client’s throat for swelling and encourage them to drink water.

Answer and Explanation

The Correct Answer is A

A. Stop the antibiotic infusion immediately and notify the healthcare provider.

  • Explanation: This is the correct first action. The client is showing signs of a severe allergic reaction, possibly anaphylaxis. Stopping the antibiotic prevents further exposure to the allergen, and notifying the provider ensures prompt medical intervention.

B. Apply a cool compress to the itchy areas and monitor for further reactions.

  • Explanation: While a cool compress may help with itching, it does not address the serious symptoms of anaphylaxis, such as difficulty swallowing and wheezing. Immediate action is required beyond just symptom management.

C. Administer diphenhydramine (Benadryl) as a first-line treatment.

  • Explanation: While antihistamines like diphenhydramine are helpful in treating mild allergic reactions, this case suggests anaphylaxis, which requires epinephrine as the first-line treatment. Administering diphenhydramine alone is not sufficient for airway compromise.

D. Assess the client’s throat for swelling and encourage them to drink water.

  • Explanation: Assessing for throat swelling is important, but encouraging oral intake is not appropriate when a client has difficulty swallowing, as this could worsen airway obstruction. The priority is stopping the medication and seeking emergency intervention.


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Related Questions

Correct Answer is A

Explanation

After a total hip arthroplasty, it is important to prevent hip dislocation. One way to do this is to place a wedge pillow between the legs. This helps to keep the hip in a stable position and prevents the hip from moving too much, which could lead to dislocation.

Correct Answer is D

Explanation

Choice A rationale
Sorbitol is a type of sugar alcohol used as a sweetener in many diet foods. It is also used in certain medications as a laxative to relieve constipation. However, it is not typically associated with liver failure and would not likely be questioned by the nurse in this context.
Choice B rationale
Lactulose is a type of sugar that is broken down in the large intestine into mild acids that draw water into the intestine, which then helps soften the stools. It is often used to treat constipation and is also used to reduce high blood ammonia levels in patients with liver disease. It would not typically be questioned by the nurse for a patient with chronic liver failure.
Choice C rationale
Neomycin is an antibiotic that is used to reduce the amount of ammonia produced by bacteria in the intestines. High levels of ammonia can cause hepatic encephalopathy, a serious complication of liver disease. Therefore, neomycin can be beneficial for patients with chronic liver failure and would not likely be questioned by the nurse.
Choice D rationale
Acetaminophen, also known as paracetamol, is a common over-the-counter medication used to relieve pain and reduce fever. However, high doses or long-term use of acetaminophen can cause liver damage. In fact, acetaminophen overdose is a common cause of acute liver failure. Therefore, the nurse should question an order for acetaminophen for a patient with chronic liver failure.

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