A client is receiving an initial dose of penicillin IV. During the infusion, the client becomes short of breath. What is the first thing the nurse should do?
Increase the head of the bed.
Place the patient in a recovery position.
Stop the infusion of the medication.
Slow down the infusion of the medication.
The Correct Answer is C
A. Increasing the head of the bed may help ease breathing but does not address the potential cause of the problem.
B. The recovery position is used for unconscious patients to maintain an open airway—not appropriate here.
C. Stopping the infusion of the medication is the first and most critical action. The client is likely experiencing an allergic reaction or anaphylaxis to penicillin, and continuing the drug could worsen symptoms.
D. Slowing the infusion does not prevent further reaction and delays stopping the exposure to the allergen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A heart rate of 160/min is more indicative of the progressive stage of shock, where compensation begins to fail.
B. Blood pressure 115/68 mmHg is within normal limits and reflects the compensatory stage, where the body maintains perfusion through mechanisms like increased heart rate and vasoconstriction.
C. Hypokalemia is not a typical finding in the compensatory stage; electrolyte shifts are more pronounced in later stages.
D. Mottled skin is a sign of poor perfusion, typically seen in the progressive or irreversible stages of shock.
Correct Answer is D
Explanation
A. Hemoglobin is important for evaluating oxygen-carrying capacity but is not directly related to digoxin safety.
B. Blood urea nitrogen (BUN) is useful in assessing renal function but is not the priority for digoxin administration.
C. Creatinine is also important for renal function assessment, especially since digoxin is renally excreted, but it is still secondary to potassium.
D. Potassium is the priority lab value to review before giving digoxin, because hypokalemia increases the risk of digoxin toxicity, which can lead to serious arrhythmias. Monitoring and correcting potassium levels is essential for client safety.
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