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 {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
The nurse should monitor the client for pneumothorax and lead dislodgement following permanent pacemaker placement.
Rationale
Pneumothorax: The procedure involves central venous access, often via the subclavian vein, which increases the risk of puncturing the pleura and causing a pneumothorax. Signs include:
Lead dislodgement: Movement or tension on the pacing lead can result in loss of pacemaker capture or failure to pace effectively. This is a priority during the first 24 hours. Indicators include:
Correct Answer is C
Explanation
A. Strict bed rest is not the priority; early mobility may be encouraged once the patient is stable.
B. Pain management is important but not the first priority in septic shock.
C. Monitoring vital signs frequently is the priority because it allows the nurse to detect changes in perfusion, blood pressure, heart rate, and oxygenation status, which are critical for timely intervention in septic shock.
D. Assisting with hygiene is part of routine care but is not a priority during the acute management of septic shock.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.