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 B
Explanation
Choice A rationale
While metformin is commonly used as a first-line medication for type 2 diabetes, this choice does not specifically address a critical safety concern related to metformin.
Choice B rationale
Metformin can interact with contrast dyes used in imaging studies, increasing the risk of acute renal failure due to lactic acidosis. Patients need to be aware of this interaction to avoid potential complications.
Choice C rationale
Metformin is used to lower blood glucose levels, not increase them. This choice is incorrect.
Choice D rationale
While metformin is associated with less weight gain compared to other diabetes medications, this choice does not address the critical interaction with contrast dye.
Correct Answer is {"dropdown-group-1":"C"}
Explanation
Choice A rationale: Furosemide is a loop diuretic used to reduce fluid overload in CHF patients. However, it can exacerbate electrolyte imbalances, particularly hypokalemia. Since the client is already experiencing muscle spasms and has low calcium levels, additional diuretic therapy could worsen these symptoms.
Choice B rationale: Metoprolol is a beta-blocker used to manage hypertension and heart rate in CHF patients. While beneficial for blood pressure control, it does not address the immediate issue of muscle spasms and constipation the client is experiencing.
Choice C rationale: Potassium chloride is indicated to address potential hypokalemia, which may be causing the client's muscle spasms. CHF patients on diuretics often experience low potassium levels, so supplementation is crucial to prevent complications and alleviate symptoms.
Choice D rationale: Acetaminophen is an analgesic and antipyretic, useful for pain and fever management. However, it does not address the client's reported muscle spasms, which are likely related to electrolyte imbalances.
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