A nurse is caring for a client who has streptococcal pneumonia and a prescription for penicillin Gby intermittent IV bolus. 10 minutes into the infusion of the third dose, the client reports that the IV site itches and that he feels dizzy and short of breath. Which of the following actions should the nurse take first?
Call the client's provider.
Stop the infusion.
Auscultate the client's breath sounds.
Elevate the head of the bed.
Elevate the head of the bed.
The Correct Answer is B
The client is exhibiting symptoms and signs of anaphylaxis. Anaphylaxis is a severe systemic allergic reaction that occurs due to allergens presenting with (itching) urticaria and sudden onset shortness of breath and/or shock. The first action should be to stop the infusion to prevent worsening the severity of the allergic reaction.
A. Important to allow for further prescription but not a priority
C. Auscultating the lungs allows the nurse to assess for the severity of the reaction but should come after stopping the infusion
D. Elevating the head can improve ventilation but is not a priority
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Related Questions
Correct Answer is A
Explanation
Acute shortness of breath in a client with a central venous catheter could be secondary to various respiratory complications such as pulmonary embolism and pneumothorax. Taking the appropriate action requires a quick assessment through auscultation as the emergency management of the various complications is different.
A. This is the immediate action to prevent more air from entering the venous system.
B. The left lateral trendelenburg position is relevant in hypotension but not a priority action.
C.uscultating breath sounds is an important assessment, especially if the cause of the shortness of breath is unclear. It can help identify wheezing, crackles, or absence of breath sounds, which may suggest conditions like pneumothorax, pulmonary embolism, or infection. However, while auscultation is an important diagnostic step, it is typically done after initial interventions (such as positioning or administering oxygen) to stabilize the client.
D. Initiating oxygen therapy is important in cases of respiratory distress but assessment is priority in this case
Correct Answer is C
Explanation
Allopurinol is used to lower uric acid levels in the body in gouty arthritis preventing acute attacks. Increasing fluid intake while taking allopurinol is important because it helps to prevent the formation of kidney stones by flushing out uric acid, a potential side effect of the medication
A. Taking an antihistamine for a rash caused by allopurinol is not recommended without consultation
B. Taking aspirin for a fever while on allopurinol is not recommended without consultation with a physician
D. Allopurinol can be taken with or without food.
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