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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Pediatric clients have a straighter and shorter ear canal as compared to adults. Pulling the auricle down and back helps straighten the ear canal, allowing easier administration of the eardrops and ensuring that they reach the tympanic membrane. This technique is preferred to avoid injury to the ear canal and tympanic membrane
B. Pulling the auricle down and out inhibits visualization of the canal
C. Pulling the auricle down and back obstructs the ear canal and hinder the proper administration of eardrops.
D. Pulling the auricle up and out is used in adults
Correct Answer is B
Explanation
alcohol withdrawal can present with agitation, anxiety, seizures and hallucinations. Diazepam is a benzodiazepine that helps to control the symptoms by potentiating the inhibitory mechanisms of the brain.
A. Buprenorphine is an opioid uses in pain management.
C. Disulfiram is used in the management of alcohol use disorder
D. Methadone is an opioid used in management of pain and opioid dependence.
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