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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The nurse should plan to take the following action:

A) Mix the medications with a semisolid food for the client.

Mixing the medications with a semisolid food, such as applesauce or pudding, can make it easier for an older adult client with dysphagia to swallow the medications safely. It helps in reducing the risk of choking and aspiration. This approach is typically used for clients who have difficulty swallowing pills.

Options B, C, and D are not recommended for a client with dysphagia:

B) Administering more than one pill at a time can increase the risk of choking and aspiration, which should be avoided.

C) Placing medications on the back of the client's tongue can also lead to difficulty swallowing and an increased risk of aspiration.

D) Tilting the client's head back when administering medications is not recommended as it can lead to aspiration. The head should be kept in a neutral position to support safe swallowing.

A. Oliguria. B. Nausea. C. Headaches. D. Weight gain.

Correct Answer is A

Explanation

Osmotic laxatives work by drawing water into the colon to soften the stool and stimulate bowel movements. However, excessive use of osmotic laxatives can cause fluid volume deficit, which is a state of reduced intravascular volume.

One of the signs of fluid volume deficit is oliguria, which means low urine output.

Choice B. Nausea is wrong because nausea is a common side effect of osmotic laxatives, not an indication of fluid volume deficit.

Choice C. Headaches is wrong because headaches are more likely to be caused by dehydration, which is a state of reduced total body water, mostly affecting the intracellular fluid compartment.

Dehydration can result from osmotic laxatives, but it is not the same as fluid volume deficit.

Choice D. Weight gain is wrong because weight gain is not a sign of fluid volume deficit.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to administer medications to an older adult client who has dysphagia. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is assessing a client who is taking an osmotic laxative. Which of the following findings should the nurse identify as an indication of fluid volume deficit?

Correct Answer is A

Explanation

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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?