A nurse is preparing to administer an IV antibiotic to a client. The client states, "I'm allergic to penicillin, and my throat feels itchy." What is the nurse's priority action?

Administer the medication as prescribed.

Withhold the medication and notify the healthcare provider.

Ask the client to rate the severity of the itchiness.

Administer an antihistamine before giving the medication.

Answer and Explanation

The Correct Answer is B

A) This choice is incorrect because administering the medication as prescribed may exacerbate the allergic reaction and is not safe without further assessment and medical guidance.

B) This choice is correct. The client's statement about being allergic to penicillin and experiencing itchiness in the throat suggests a potential allergic reaction. The nurse should withhold the medication and promptly notify the healthcare provider to assess the client's allergic response and determine an alternative course of action.

C) This choice is not the priority action. While assessing the severity of the itchiness is important, the nurse's priority is to withhold the medication and notify the healthcare provider about the potential allergic reaction.

D) This choice is incorrect because administering an antihistamine before notifying the healthcare provider may mask the symptoms of the allergic reaction and delay appropriate management.

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Correct Answer is A

Explanation

A) This choice is correct. Changing the IV tubing every 24 hours is a recommended intervention to reduce the risk of catheter-related bloodstream infections (CRBSIs) by minimizing the accumulation of microorganisms in the tubing.

B) This choice is incorrect because administering antibiotics prophylactically is not a standard practice for preventing CRBSIs, and it can contribute to antibiotic resistance.

C) This choice is incorrect because keeping the IV bag above the level of the heart is a technique used to regulate IV flow rate, but it is not specifically related to preventing CRBSIs.

D) This choice is incorrect because using a large-gauge catheter is not a preventive measure for CRBSIs. The appropriate catheter size should be based on the client's clinical condition and the prescribed therapy.

A. Infiltration B. Phlebitis C. Fluid overload D. Anaphylaxis

Correct Answer is D

Explanation

A) This choice is incorrect because infiltration is not typically associated with symptoms of chest pain, difficulty breathing, decreased blood pressure, and weak pulse.

B) This choice is incorrect because phlebitis does not cause sudden onset chest pain, difficulty breathing, decreased blood pressure, and weak pulse.

C) This choice is incorrect because fluid overload is not associated with symptoms like chest pain and decreased blood pressure. It may cause elevated blood pressure due to increased fluid volume.

D) This choice is correct. The client's symptoms of sudden chest pain, difficulty breathing, decreased blood pressure, and weak pulse are indicative of anaphylaxis, a severe allergic reaction. Anaphylaxis can occur in response to an allergen in the IV fluid or medication and can be life-threatening if not treated promptly.

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A nurse is preparing to administer an IV antibiotic to a client. The client states, "I'm allergic to penicillin, and my throat feels itchy." What is the nurse's priority action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at risk for developing a catheter-related bloodstream infection (CRBSI) from the IV line. Which intervention should the nurse implement to reduce the risk of CRBSI?

Correct Answer is A

Explanation

A client receiving IV fluids suddenly complains of chest pain and difficulty breathing. The nurse quickly assesses the client's vital signs and observes decreased blood pressure and weak pulse. The nurse should suspect which complication of IV therapy?

Correct Answer is D

Explanation

A nurse is preparing to administer an IV antibiotic to a client. The client states, "I'm allergic to penicillin, and my throat feels itchy." What is the nurse's priority action?

A client receiving IV therapy suddenly experiences chest pain, dyspnea, and tachycardia. The nurse should recognize these symptoms as potential signs of which complication?

A nurse is caring for a client with an IV catheter in place for medication administration. The nurse observes redness, warmth, and swelling around the insertion site, and the client reports tenderness and pain. Which complication of IV therapy should the nurse suspect?

A nurse is caring for a client receiving IV fluids. The client complains of pain, burning, and redness at the insertion site. Upon assessment, the nurse notes swelling and coolness around the site. What is the nurse's priority action?

A client receiving IV therapy develops a fever, rash, and elevated liver enzymes. The nurse should recognize these symptoms as potential signs of which type of hypersensitivity reaction?

A nurse is starting an IV infusion for a client and observes that the IV catheter has punctured the vein and fluid is leaking into the surrounding tissues. The client complains of burning pain at the insertion site. Which complication of IV therapy should the nurse suspect?

A nurse is preparing to initiate IV therapy for a client with severe dehydration. Which indication supports the use of IV therapy in this situation?

A nurse is caring for a client who requires prolonged IV therapy. What is the nurse's best action to prevent the development of complications associated with IV therapy?