A nurse is caring for a client who develops an anaphylactic reaction to IV antibiotic administration.
After assessing the client’s respiratory status and stopping the medication infusion, which of the following actions should the nurse take next?
Administer epinephrine IM.
Replace the infusion with 0.9% sodium chloride.
Give diphenhydramine IM.
Elevate the clients legs and feet.
The Correct Answer is A
Epinephrine (adrenaline) is the first-line treatment for anaphylaxis, a severe and potentially life-threatening allergic reaction. Epinephrine works by reducing the body’s allergic response and improving the breathing and circulation of the client. Epinephrine should be given as soon as possible after the onset of anaphylaxis symptoms, using an auto-injector device if available.
Choice B is wrong because replacing the infusion with 0.9% sodium chloride (normal saline) is not enough to treat anaphylaxis. Normal saline can help maintain the blood pressure and hydration of the client, but it does not reverse the allergic reaction or improve the breathing of the client. Normal saline can be given after epinephrine, but not before or instead of it.
Choice C is wrong because giving diphenhydramine IM is not enough to treat anaphylaxis. Diphenhydramine is an antihistamine that can help relieve some of the symptoms of anaphylaxis, such as itching and hives, but it works too slowly and does not address the more serious effects of anaphylaxis on the breathing and circulation of the client. Diphenhydramine can be given after epinephrine, but not before or instead of it.
Choice D is wrong because elevating the client's legs and feet is not enough to treat anaphylaxis. Elevating the legs and feet can help increase the blood flow to the vital organs, but it does not reverse the allergic reaction or improve the breathing of the client. Elevating the legs and feet can be done after epinephrine, but not before or instead of it.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Choice B: Compare the client’s wristband to the medication administration record.
This is the first step to ensure the right patient receives the right medication. This is part of the “five rights” of medication administration.
Choice A: Remove the medication from the dispensing system. This is the second step to obtain the medication from the appropriate source and check the expiration date and dosage.
Choice C: Document administration of the medication. This is the last step to record the time, route, dose, and any adverse effects of the medication.
Choice D: Open the medication package. This should not be done before comparing the client’s wristband to the medication administration record, as it may result in giving the wrong medication or dose to the wrong patient.
Choice E: Obtain the client’s apical heart rate. This should not be done before opening the medication package, as it may delay theadministration of the medication or cause confusion with other medications.
Correct Answer is A
Explanation
The client should stay upright for at least 15 minutes after taking ferrous gluconate to prevent oesophagal irritation. Choice B is wrong because taking an antacid with ferrous gluconate can decrease its absorption and effectiveness.
Choice C is wrong because taking ferrous gluconate with milk can also reduce its absorption and cause gastrointestinal distress.
Choice D is wrong because black stools are a common and harmless side effect of ferrous gluconate and do not indicate a need to notify the provider. Ferrous gluconate is an iron supplement used to treat or prevent iron deficiency anaemia, a condition where the body does not have enough red blood cells to carry oxygen to the tissues.
Iron is an essential component of haemoglobin, the protein that carries oxygen in the blood.
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