Thirty minutes after taking a prescribed medication, the client has the following symptoms: wheezing, anxiety, dizziness, and large red blotches on the face.
The nurse will:

Check to see if the client has an order for a cream to diminish itching.

Note in the client's chart that there may be an allergy to the drug.

Encourage the client to force fluids to flush the drug from the body.

Call for another person's help to call the physician stat.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Checking for a cream order is insufficient for anaphylactic-like symptoms. Wheezing, dizziness, and anxiety indicate a systemic hypersensitivity reaction, potentially compromising respiratory and cardiovascular systems. Topical treatments address localized dermatological issues, not acute, life-threatening systemic responses requiring immediate medical intervention.

Choice B rationale

Simply noting a possible drug allergy in the chart without immediate action is insufficient for these severe symptoms. Wheezing and dizziness suggest anaphylaxis, a life-threatening acute hypersensitivity reaction involving systemic histamine release, leading to bronchoconstriction and vasodilation. Prompt intervention, like epinephrine, is critical.

Choice C rationale

Encouraging fluid intake to flush the drug is ineffective and potentially harmful during an acute allergic reaction. The body's elimination processes are not significantly accelerated by increased fluid intake to counteract rapid systemic histamine release. This response delays critical medical intervention for potentially life-threatening symptoms.

Choice D rationale

Calling for help and contacting the physicianSTAT is the immediate and appropriate action. Wheezing, anxiety, dizziness, and blotches suggest an anaphylactic reaction, a severe, rapid-onset allergic response requiring urgent medical attention. Prompt communication facilitates rapid assessment, intervention (e.g., epinephrine), and management of potential airway compromise.

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Correct Answer is ["5"]

Explanation

Step 1 is: Calculate the volume to administer. 75 mg ÷ (15 mg/mL) = 5 mL.

A. Instill 5 ml of water to rinse the tube. B. Check the tube placement. C. Lay the client flat. D. Assess the client's bowel sounds.

Correct Answer is B

Explanation

Choice A rationale

Instilling water to rinse the tube is an important step after medication administration or prior to administering incompatible medications, but it is not the initial and most crucial step before delivering any drug. Placement verification is paramount.

Choice B rationale

Scientifically, confirming tube placement is the absolute first and most critical step before administering any substance, including medication, through an enteral tube. Misplaced tubes can lead to aspiration pneumonia or inefficient drug absorption, posing significant patient safety risks.

Choice C rationale

Laying the client flat may increase the risk of aspiration, especially if the tube is misplaced or if the client has impaired gag reflex. Proper positioning, typically semi-Fowler's, is crucial for safe enteral feeding and medication administration.

Choice D rationale

Assessing bowel sounds is important for evaluating gastrointestinal motility and absorption capacity before initiating or continuing enteral feedings, but it is not the primary immediate safety check required before administering a single dose of medication.

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Thirty minutes after taking a prescribed medication, the client has the following symptoms: wheezing, anxiety, dizziness, and large red blotches on the face. The nurse will:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The physician has ordered Zantac elixir 75 mg PO bid for heartburn. The medication is supplied in 15 mg/mL. How many milliliters will the nurse administer? (Shade CUP #1 to correct dose & LABEL CORRECTLY TO RECEIVE CREDIT)

Correct Answer is ["5"]

Explanation

Before delivering a drug through an enteral tube, it is most important for the nurse to do which of the following FIRST?

Correct Answer is B

Explanation

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Thirty minutes after taking a prescribed medication, the client has the following symptoms: wheezing, anxiety, dizziness, and large red blotches on the face.
The nurse will: