Ten minutes after initiating an intravenous antibiotic, the client complains of shortness of breath, itching, and difficulty swallowing. What is the nurse's initial action?

Prepare to administer prescribed epinephrine

Assess the client's apical pulse and blood pressure

Stop infusing the client's intravenous antibiotic

Administer 4 liters of oxygen via nasal cannula

Answer and Explanation

The Correct Answer is C

A.   While epinephrine is crucial in cases of anaphylaxis, it should not be the first action taken. The immediate priority is to stop the offending medication.
B.   While assessing vital signs is important, it is not the first action. The primary concern is to halt the exposure to the potential allergen.
C.   The first action in this situation should be to immediately stop the infusion of the antibiotic. This prevents further exposure to the allergen and is critical to managing the potential anaphylactic reaction.

D.   While providing oxygen may be necessary later if the client is hypoxic, the immediate priority is to stop the infusion of the antibiotic first. Administering oxygen is important but comes after halting the offending agent.

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Correct Answer is B

Explanation

This is the correct time to draw the peak level. The peak level is the highest concentration of the drug in the blood, which typically occurs about 30 minutes to an hour after the end of the infusion.

A. take vital signs. B. administer 1 mg glucagon subcutaneously. C. obtain a blood glucose reading. D. notify the physician.

Correct Answer is C

Explanation

A. While taking vital signs can provide useful information about the client's overall condition, it does not directly address the immediate concern of potential hypoglycemia. The priority is to assess blood glucose levels, as this will guide further actions.
B. Glucagon is used for severe hypoglycemia when the client is unable to consume glucose orally. However, before administering glucagon, it is essential to confirm hypoglycemia by checking the blood glucose level. This ensures that glucagon is only used when absolutely necessary.
C. Checking the blood glucose level will quickly determine whether the client is experiencing hypoglycemia. If the blood glucose is low, appropriate treatment (such as administering glucose or a fast-acting carbohydrate) can be initiated. If it’s within normal limits, other potential causes for the symptoms can be explored.

D. While it may be necessary to notify the physician depending on the outcome of the blood glucose reading or if the client’s condition worsens, it is not the first action. Immediate assessment of blood glucose is essential to determine the appropriate course of action.

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Ten minutes after initiating an intravenous antibiotic, the client complains of shortness of breath, itching, and difficulty swallowing. What is the nurse's initial action?

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Naxlex Comprehensive Predictor Exams

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