A postoperative patient is undergoing antibiotic therapy. She has never had any problems taking medications in the past. When the nurse hung the second dose of IV antibiotics, the patient suddenly developed hives and itching. The nurse recognized this was most likely a(n):

allergic reaction.

side effect.

toxic effect.

idiosyncratic reaction.

Answer and Explanation

The Correct Answer is A

A. An allergic reaction is an immune response to a medication, even if the patient has taken the medication before without issues. Symptoms like hives and itching are classic signs of an allergic reaction.
B. A side effect is an expected, often mild and predictable reaction to a medication, not typically involving an immune response and severe symptoms like hives.
C. A toxic effect refers to harmful effects from a medication overdose or accumulation in the body, not sudden onset after an appropriate dose.
D. An idiosyncratic reaction is an uncommon response not related to allergies or toxic effects, usually not presenting with hives and itching.

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Correct Answer is C

Explanation

A. "Client assisted OOB, instructed to splint ABD" is clear and uses standard abbreviations (OOB: out of bed, ABD: abdomen).
B. "Urine collected for UA and C & S" is clear and uses standard abbreviations (UA: urinalysis, C & S: culture and sensitivity).
C. "Prescription received for MSO4 4.0 mg PRN pain" is problematic because "MSO4" is an ambiguous abbreviation that can be confused with other medications. It should be written as "morphine sulfate" for clarity. Additionally, the trailing zero in "4.0 mg" can lead to dosing errors; it should be written as "4 mg."
D. "12 units of regular insulin administered subcut" is clear and uses standard terminology (subcut: subcutaneous).

A. Leave the medication at the client's bedside. B. Come back in a few minutes to administer the medication in order to allow the client to finish with therapy. C. Prepare the medication in the medication room to quickly administer to the client once finished with therapy. D. Document the medication was given because the client will take it when they return to their room.

Correct Answer is B

Explanation

Leaving medication at the client's bedside is unsafe as it can lead to medication errors, missed doses, or accidental ingestion.
B. Coming back in a few minutes to administer the medication respects the client’s therapy schedule and ensures the nurse can directly observe the client taking the medication, ensuring proper administration and adherence.
C. Preparing the medication in the medication room ahead of time can be efficient but doesn’t address the need to personally administer the medication and confirm the client takes it.
D. Documenting the medication was given without actually administering it is unethical and against best practices as it assumes the client will take the medication without verification.

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A postoperative patient is undergoing antibiotic therapy. She has never had any problems taking medications in the past. When the nurse hung the second dose of IV antibiotics, the patient suddenly developed hives and itching. The nurse recognized this was most likely a(n):

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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A postoperative patient is undergoing antibiotic therapy. She has never had any problems taking medications in the past. When the nurse hung the second dose of IV antibiotics, the patient suddenly developed hives and itching. The nurse recognized this was most likely a(n):

The nurse goes into a patient's room and administers her 0900 medications. When should the nurse document that the medications were given?