The hospital nurse is preparing to administer a dose of penicillin antibiotic when the patient says, "The last time I took penicillin I got a very itchy rash and started wheezing." Which action should the nurse take?
Assure the patient that the reaction was probably a side effect and not an allergy.
Call the pharmacist.
Withhold the medication and contact the prescriber.
Administer the antibiotic and observe carefully for a reaction.
The Correct Answer is C
A. Assure the patient that the reaction was probably a side effect and not an allergy: An itchy rash and wheezing after penicillin are classic signs of an allergic reaction, potentially IgE-mediated. Dismissing these symptoms as a minor side effect is unsafe, as repeat exposure could trigger anaphylaxis, including life-threatening bronchospasm, hypotension, or cardiovascular collapse.
B. Call the pharmacist: While pharmacists can provide guidance on alternative medications or interactions, immediate withholding of the suspected allergen and notifying the prescriber takes priority. Pharmacist consultation is supportive but does not replace urgent clinical decision-making regarding patient safety.
C. Withhold the medication and contact the prescriber: Withholding the penicillin prevents further exposure to a known allergen, and contacting the prescriber allows for safe substitution with an alternative antibiotic. This action aligns with best practices for allergy management and patient safety protocols in medication administration.
D. Administer the antibiotic and observe carefully for a reaction: Administering a medication despite a reported allergic reaction places the patient at high risk for immediate hypersensitivity reactions. Observation alone is insufficient to mitigate the potential for severe outcomes such as anaphylaxis, and this approach violates safe medication administration standards.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Stage 1 pressure injury: Stage 1 pressure injuries are characterized by intact skin with localized nonblanchable redness, typically over bony prominences. The presence of a large, open wound with granulation tissue and irregular borders on the lower leg does not fit the criteria for a Stage 1 injury.
B. Venous stasis ulcer: Venous stasis ulcers are commonly located on the medial lower leg near the ankle and are often shallow with irregular borders. The wound bed contains red granulation tissue and has areas of slough. Surrounding skin shows brownish discoloration (hemosiderin staining) due to chronic venous insufficiency and red blood cell leakage as seen in this patient.
C. Arterial ulcer: Arterial ulcers generally occur on the distal lower extremities, such as the toes or lateral malleolus, and have well-defined borders with a pale, dry wound bed. They are often painful and associated with diminished pulses, which differs from the characteristics of the wound observed here.
D. Diabetic ulcer: Diabetic ulcers most commonly appear on pressure points of the foot, such as the plantar surface or under the metatarsal heads, and are usually neuropathic in origin. The medial lower leg location and the features of venous insufficiency make a diabetic ulcer less likely.
Correct Answer is C
Explanation
A. Turn and reposition every 2 hours: Repositioning every 2 hours is a standard evidence-based intervention to prevent pressure injuries. Frequent repositioning relieves sustained pressure over bony prominences, improves tissue perfusion, and reduces the risk of skin breakdown.
B. Completing personal hygiene and apply skin barrier products: Maintaining skin hygiene and using moisture barrier creams protects skin from irritants such as urine, feces, and sweat. These measures help preserve skin integrity, reduce maceration, and prevent breakdown, making them appropriate preventive interventions.
C. Reposition the patient every 8 hours: Repositioning only every 8 hours is inadequate for pressure injury prevention. Prolonged pressure beyond 2–3 hours can compromise capillary blood flow, leading to tissue ischemia and increased risk of skin breakdown. This intervention does not align with current best practices and should be questioned.
D. Cushion vulnerable parts of the body and redistribute body weight: Using pillows, foam pads, or specialized mattresses to offload pressure on bony prominences is a recommended intervention. Redistributing weight reduces localized pressure, improves circulation, and minimizes the risk of developing pressure injuries.
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