A nurse started a client's gentamicin via an intravenous (IV) route that is programmed to infuse over one hour.
Ten minutes after the administration, the client reports dyspnea, generalized rash, and itchiness.
What is the priority intervention for this client?
Stop the infusion immediately.
Administer an IV fluid bolus to flush the medication.
Encourage the client to take deep breaths and remain calm.
Administer oxygen via nasal cannula.
The Correct Answer is A
Choice A rationale
Stopping the infusion immediately is crucial to prevent further exposure to the allergen causing the adverse reaction. This intervention halts the administration of gentamicin, which is likely causing the dyspnea, rash, and itchiness. Prompt discontinuation of the medication minimizes the severity of the allergic reaction and allows for further medical management.
Choice B rationale
Administering an IV fluid bolus to flush the medication is not the priority intervention in this case. While it might help to clear the medication from the bloodstream, it does not address the immediate need to stop the allergen exposure and manage the allergic reaction.
Choice C rationale
Encouraging the client to take deep breaths and remain calm is supportive, but it does not address the root cause of the allergic reaction, which is the administration of gentamicin. The immediate priority is to stop the infusion and then manage the symptoms.
Choice D rationale
Administering oxygen via nasal cannula may help alleviate respiratory distress, but it is not the priority intervention. The primary step is to stop the infusion to prevent further exposure to the allergen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Condition: Post-operative pain.
2 actions:
Administer acetaminophen (Tylenol) for mild pain,
Apply a warm compress to the surgical site.
2 parameters:
Pain level on a 0-10 scale,
Surgical site appearance.
Rationale for correct condition: Post-operative pain is expected after surgery and the client reports mild pain (2 out of 10). Managing pain is crucial for recovery and mobility. Mild pain indicates the need for non-opioid analgesics. Pain management enhances comfort and healing. Addressing pain prevents complications.
Rationale for actions: Administering acetaminophen targets mild pain effectively. It is appropriate for the reported pain level. Warm compresses can soothe soreness and reduce pain without medication. Encourages blood flow and healing. Encouraging ambulation prevents DVT but is not pain-focused. Monitoring for infection is important but not the priority for mild pain. Ondansetron treats nausea, not pain.
Rationale for parameters: Pain level on a 0-10 scale assesses pain management effectiveness. Monitoring pain ensures appropriate interventions. Surgical site appearance checks for complications affecting pain, like infection. Respiratory rate is stable and less relevant. Oxygen saturation is normal, unrelated to pain. Urine output monitors hydration, not pain.
Rationale for incorrect conditions: Post-operative nausea and vomiting is not reported. Surgical site infection would show signs like redness or fever. DVT focuses on circulation, not pain.
Correct Answer is C
Explanation
Choice A rationale
Acetaminophen is not used for preventing osteoporosis.
Choice B rationale
Acetaminophen does not prevent urinary retention.
Choice C rationale
Acetaminophen is commonly used as an analgesic for pain relief and as an antipyretic to reduce fever.
Choice D rationale
Acetaminophen does not affect blood sugar levels.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.