A nurse is assisting with the care of a client.

• At 1600, the nurse administered an antibiotic as prescribed.
• At 1630, the nurse noted that the client’s bilateral breath sounds were clear and present throughout.
• The client reports itching on the chest and has urticaria over the chest and trunk.
• The client states they are having difficulty swallowing and feel as if there is a lump in their throat.
• The nurse hears bilateral breath sounds with scattered wheezing throughout.

What should the nurse do next?

A. Stop the antibiotic infusion immediately and notify the healthcare provider.

• Explanation: This is the correct first action. The client is showing signs of a severe allergic reaction, possibly anaphylaxis. Stopping the antibiotic prevents further exposure to the allergen, and notifying the provider ensures prompt medical intervention.

B. Apply a cool compress to the itchy areas and monitor for further reactions.

• Explanation: While a cool compress may help with itching, it does not address the serious symptoms of anaphylaxis, such as difficulty swallowing and wheezing. Immediate action is required beyond just symptom management.

C. Administer diphenhydramine (Benadryl) as a first-line treatment.

• Explanation: While antihistamines like diphenhydramine are helpful in treating mild allergic reactions, this case suggests anaphylaxis, which requires epinephrine as the first-line treatment. Administering diphenhydramine alone is not sufficient for airway compromise.

D. Assess the client’s throat for swelling and encourage them to drink water.

• Explanation: Assessing for throat swelling is important, but encouraging oral intake is not appropriate when a client has difficulty swallowing, as this could worsen airway obstruction. The priority is stopping the medication and seeking emergency intervention.