A patient who is receiving the sulfonamide medication, trimethoprim/sulfamethoxazole for an urinary tract infection. On entering the room the nurse notices the patient presents with a red-to-purple rash that is reported as painful. Which response by the nurse is most appropriate?
"I can get a bath started. Sitting in the tub can help with the itching"
"This is an expected side effect. The symptoms are harmless and will go away within a day or two
“I will administer diphenhydramine to reverse these symptoms."
"I will stop this medication immediately and consult your physician for further orders"
The Correct Answer is D
A. "I can get a bath started. Sitting in the tub can help with the itching": While baths may relieve mild itching, a painful red-to-purple rash from trimethoprim/sulfamethoxazole may indicate a severe hypersensitivity reaction, such as Stevens-Johnson syndrome, which requires immediate action rather than symptomatic care.
B. "This is an expected side effect. The symptoms are harmless and will go away within a day or two": A painful, spreading rash is not harmless and is not a common side effect of sulfonamides. Dismissing it could delay urgent treatment and place the patient at serious risk.
C. "I will administer diphenhydramine to reverse these symptoms": Antihistamines may help mild allergic reactions but cannot reverse severe mucocutaneous reactions like Stevens-Johnson syndrome. Immediate discontinuation and medical evaluation are required.
D. "I will stop this medication immediately and consult your physician for further orders": Stopping the suspected medication and notifying the provider is critical to prevent progression of a potentially life-threatening hypersensitivity reaction. Prompt medical intervention and supportive care are necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Injections should be administered into the fatty part under your skin.":Subcutaneous tissue, typically in the abdomen, thigh, or upper arm, allows for slower, more consistent absorption of insulin. Injecting into the fatty layer reduces the risk of rapid absorption or injury to underlying muscle or blood vessels.
B. "If you run out of insulin syringes, it is ok to use another type of syringe, as long as you are sure you are administering the correct dose.":Using syringes designed for different insulin concentrations or volumes can lead to dosing errors and hypoglycemia or hyperglycemia. Only the correct syringe type for the insulin concentration should be used.
C. "Injections will work most quickly when given deeply into the gluteus muscle.":Intramuscular injection accelerates insulin absorption unpredictably and increases the risk of hypoglycemia. Insulin should not be injected into muscle unless specifically prescribed for rapid absorption in exceptional circumstances.
D. "If you are eating there is no need to check glucose before administration.":Blood glucose should be checked before insulin administration to prevent hypoglycemia. Skipping glucose monitoring can be dangerous, especially with rapid-acting insulin.
Correct Answer is D
Explanation
A. I will not bother to check the expiration date of my acetaminophen medication before taking it:Taking expired medications can reduce effectiveness or increase the risk of adverse effects. Checking the expiration date is an important safety practice.
B. OTC medications are safe enough not to need a doctor's prescription so taking a little more than the bottle says can help with severe pain:Exceeding the recommended dose of acetaminophen can lead to hepatotoxicity and liver failure. Following dosing instructions is essential for safety.
C. I will mix my acetaminophen with alcohol to enhance its pain-relieving effects:Alcohol combined with acetaminophen greatly increases the risk of liver damage. These substances should never be taken together.
D. I will check the labels of my other over-the-counter medications to ensure I am not consuming multiple products containing acetaminophen:Many combination cold, flu, or pain medications contain acetaminophen. Checking labels prevents accidental overdose, supporting safe use and demonstrating appropriate patient understanding.
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