A nurse is assessing a client who is receiving penicillin IV.
For which of the following findings should the nurse report to the provider as a manifestation of anaphylaxis?

The correct answer is Choice B.

Choice A rationale:

Documenting the administration of the medication is crucial for maintaining accurate records and ensuring accountability. However, it is not the first action to take. The priority is to ensure the correct patient receives the correct medication.

Choice B rationale:

Identifying the client using two identifiers is the first and most critical step. This action ensures that the right patient receives the right medication, thereby minimizing the risk of medication errors.

Choice C rationale:

Comparing the amount of medication available to the inventory record is important for maintaining accurate inventory and preventing misuse or theft of controlled substances. However, this is not the first step in the process of administering medication to a patient in pain.

Choice D rationale:

Removing the medication from the medication dispensing cabinet is part of the process, but it should only be done after the patient has been properly identified to avoid any potential errors.

The correct answer is Choice C.

Choice A rationale:

• This response is not appropriate because it is judgmental and may make the client feel defensive.
• It is important for the nurse to respect the client's right to make their own decisions about their health care.
• Telling the client what they should do can undermine their autonomy and potentially damage the nurse-client relationship.
• It's crucial for the nurse to remain objective and avoid imposing their personal opinions or beliefs onto the client.

Choice B rationale:

• This response is also not appropriate because it is using scare tactics to try to persuade the client to get the vaccine.
• This approach can be counterproductive and may further alienate the client.
• It's important to provide accurate information about the risks and benefits of the vaccine in a neutral and non-threatening manner.

Choice C rationale:

• This is the most appropriate response because it acknowledges the client's right to refuse the vaccine while still encouraging them to get it.
• It also demonstrates respect for the client's autonomy and validates their feelings.
• This approach is more likely to foster a positive nurse-client relationship and keep the door open for future discussions about vaccination.

Choice D rationale:

• This response is not accurate because the influenza vaccine is not mandatory for all clients before discharge.
• It is important for the nurse to provide accurate information to the client.
• Threatening the client with an against medical advice form is not appropriate and may be considered a form of coercion.