A nurse is preparing to administer diphenhydramine 25 mg PO every 6 hr. to an older adult client who has rhinitis. The amount available is diphenhydramine syrup 12.5 mg/5 mile How many ml should the nurse administer?
(Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Choice A Reason:
“I'm going to take your heart rate”. This statement is incorrect. Monitoring vital signs like heart rate is essential in assessing a client's condition. However, in this scenario, the client's report of hives, itching, and a potential allergic reaction is more indicative of an immediate concern for anaphylaxis. While monitoring heart rate is relevant, assessing for signs of anaphylaxis, especially difficulty breathing, takes precedence due to the urgency of potential respiratory distress.
Choice B Reason:
"I need to give you diphenhydramine". This statement is incorrect, administering an antihistamine like diphenhydramine can help alleviate allergic symptoms, including itching and hives. However, confirming the severity of the reaction and ensuring there are no life-threatening symptoms such as breathing difficulties is the immediate priority before administering any medication.
Choice C Reason:
"Are you having difficulty breathing?" This statement is correct. This question directly assesses the client's respiratory status, a crucial indicator of anaphylaxis. If the client is experiencing difficulty breathing, it indicates a severe allergic reaction that requires immediate intervention and emergency medical attention. Recognizing and addressing potential respiratory distress is of utmost importance in managing an allergic reaction to medication.
Choice D Reason:
"Do you have any allergies to medications? This statement is incorrect. Understanding the client's medical history, including allergies, is crucial. However, in this acute situation where the client is already experiencing symptoms of a potential allergic reaction shortly after receiving penicillin, addressing the current symptoms and assessing for signs of anaphylaxis is the most immediate concern.

Choice A Reason:

Nerve damage is incorrect. Nerve damage typically presents with symptoms such as altered sensation, numbness, tingling, or shooting pain along the path of the nerve. The symptoms described in the scenario are more indicative of localized inflammation rather than nerve-related issues.

Choice B Reason:

Infection is incorrect. Infection at the insertion site can manifest with redness, warmth, tenderness, and possibly purulent drainage. While infection is a potential complication of IV therapy, the symptoms described might indicate a different issue.

Choice C Reason:

Infiltration is correct. Infiltration occurs when the IV fluid leaks into the surrounding tissues. Symptoms often include swelling, coolness, and tenderness at the site due to the fluid accumulating in the tissue instead of going into the vein. These symptoms align with the description provided.

Choice D Reason:

Phlebitis is incorrect. Phlebitis is the inflammation of a vein, typically presenting with redness, warmth, and tenderness along the vein's path.