Patient Data

 

Review H and P, nurse's notes, flow sheet, and prescriptions.

Click to mark whether the assessment finding represents a therapeutic result of the bisacodyl administered, a non-therapeutic side effect, or an unrelated finding. Each row must have one option selected.

A. Give with prescribed antihistamine: Administering an antihistamine may help manage mild allergic reactions but does not prevent the risk of a serious, potentially life-threatening anaphylactic reaction. It is unsafe to rely solely on antihistamines when the client has a known severe penicillin allergy and is prescribed a related antibiotic like cephalexin.

B. Administer the medication as prescribed: Cephalexin is a cephalosporin, and there is a known cross-sensitivity with penicillins, especially in clients with a history of anaphylaxis. Administering the drug without verifying safety first exposes the client to unnecessary and serious risk.

C. Monitor the client for a rash or hives: While monitoring is important after administering any new medication, simply observing for early signs of an allergic reaction is not a proactive or safe strategy when anaphylaxis is a possibility. Prevention of exposure is the priority.

D. Contact the healthcare provider (HCP): Clients with a history of anaphylaxis to penicillin are at increased risk for cross-reactivity with cephalosporins. The safest action is to notify the HCP immediately to discuss an alternative antibiotic, avoiding the possibility of a dangerous allergic response.

A. Insomnia may occur while taking the medication: St. John's wort can increase central nervous system stimulation, leading to side effects like insomnia, restlessness, and anxiety. Educating the client that sleep disturbances may occur is appropriate and consistent with known herb effects.

B. Another form of contraception is not needed: St. John's wort can induce cytochrome P450 enzymes, leading to faster metabolism and reduced effectiveness of hormonal contraceptives like birth control pills. Clients must be advised to use an additional non-hormonal contraceptive method to prevent unintended pregnancy.

C. Hard candy can be used for a dry mouth: Dry mouth is a recognized side effect of St. John's wort. Sucking on hard candy, increasing oral hydration, or chewing sugarless gum are appropriate and effective ways to manage this discomfort.

D. Sensitivity to the sun can develop: Photosensitivity is a well-documented adverse effect of St. John's wort. Clients should be instructed to use sunscreen, wear protective clothing, and limit sun exposure to prevent sunburns or skin reactions.