A client with a history of anaphylactic reaction to penicillin receives a prescription for cephalexin 500 mg PO twice daily. Which action should the nurse take?
Contact the healthcare provider.
Give with prescribed antihistamine.
Administer the medication as prescribed.
Monitor the client for a rash or hives.
The Correct Answer is A
Choice A Reason:
Contact the healthcare provider: Given the client’s history of anaphylactic reaction to penicillin, there is a potential risk of cross-reactivity with cephalexin, a cephalosporin. Although the risk of cross-reactivity is relatively low, it is still significant enough to warrant caution. Studies indicate that 1-4% of people with a true penicillin allergy may also react to cephalosporins. Therefore, the nurse should contact the healthcare provider to discuss alternative antibiotics or additional precautions.
Choice B Reason:
Give with prescribed antihistamine: While antihistamines can help manage mild allergic reactions, they are not sufficient to prevent or treat anaphylaxis. Anaphylactic reactions require immediate medical intervention, including epinephrine administration. Therefore, relying solely on antihistamines is not an appropriate or safe action in this scenario.
Choice C Reason:
Administer the medication as prescribed: Administering cephalexin without consulting the healthcare provider could put the client at risk of a severe allergic reaction. Given the client’s history of anaphylaxis to penicillin, it is crucial to verify the safety of cephalexin with the healthcare provider before administration.
Choice D Reason:
Monitor the client for a rash or hives: While monitoring for allergic reactions is essential, it should not be the primary action in this case. The priority is to prevent a potential severe allergic reaction by consulting the healthcare provider before administering the medication. Monitoring alone does not address the underlying risk of cross-reactivity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Rinsing the mouth after each use of an inhaler is a recommended practice, especially for inhalers containing corticosteroids, to prevent oral thrush and other side effects. Although ipratropium is not a corticosteroid, rinsing the mouth can still help reduce any potential irritation or unpleasant taste.
Choice B reason:
Storing the medication at room temperature is appropriate for most inhalers, including ipratropium2. This ensures the medication remains effective and safe to use. It is important to keep the inhaler away from extreme temperatures and direct sunlight.
Choice C reason:
Attaching a spacer device to the inhaler can be beneficial, especially for patients who have difficulty coordinating the timing of inhalation with the activation of the inhaler. A spacer helps ensure that more medication reaches the lungs rather than being deposited in the mouth or throat.
Choice D reason:
Priming the inhaler with 7 pumps is excessive. Typically, ipratropium inhalers require priming with only 2 to 4 sprays before the first use or if the inhaler has not been used for a few days. Over-priming can waste medication and may indicate that the client needs additional instruction on proper inhaler use.
Correct Answer is D
Explanation
Choice A reason: Giving the next scheduled dose without further assessment is not advisable. An INR of 2.8 is within the therapeutic range for many conditions treated with warfarin, but it is important to ensure that the INR is stable and not trending higher, which could increase the risk of bleeding.
Choice B reason: Obtaining another blood sample might be necessary if there is suspicion of an error or if the INR is unexpectedly high or low. However, in this scenario, the INR is within the therapeutic range, so this action is not immediately necessary.
Choice C reason: Monitoring for signs of bleeding is always important for clients on warfarin, but it does not address the immediate need to communicate with the healthcare provider about the current INR level and any potential adjustments to the medication.
Choice D reason: Notifying the healthcare provider is the most appropriate action. The healthcare provider needs to be aware of the current INR level to make any necessary adjustments to the warfarin dosage and to provide further instructions on monitoring and follow-up.
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