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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?

Stop the antibiotic infusion immediately and notify the healthcare provider.

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

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

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

Answer and Explanation

The Correct Answer is A

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.

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Correct Answer is ["0.5"]

Explanation

Step 1: The available dose of epinephrine is 0.5 mg in 0.5 mL.

Step 2: The patient needs to administer 0.5 mg of epinephrine.

Step 3: Since the available dose is 0.5 mg/0.5 mL, for 0.5 mg of epinephrine, the patient should be taught to administer 0.5 mL1.

A. Epinephrine (Adrenaline). B. Dexamethasone (Decadron). C. 0.9% Normal Saline. D. Dobutamine (Dobutrex).

Correct Answer is A

Explanation

Choice A rationale
Epinephrine is the first-line treatment for anaphylactic shock. It works by constricting blood vessels to increase blood pressure, relaxing smooth muscles in the lungs to reduce wheezing and improve breathing, stimulating the heart, and reducing hives and swelling around the face and lips.
Choice B rationale
Dexamethasone is a corticosteroid that can be used to treat anaphylactic shock, but it is not the first-line treatment. It works by reducing inflammation.
Choice C rationale
0.9% Normal Saline is a type of intravenous fluid that can be used to treat anaphylactic shock, but it is not the first-line treatment. It works by increasing fluid volume in the body to help maintain blood pressure.
Choice D rationale
Dobutamine is a medication that can be used to treat anaphylactic shock, but it is not the first-line treatment. It works by stimulating the heart muscle to increase cardiac output, which can help maintain blood pressure.

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Naxlex Comprehensive Predictor Exams

The nurse is instructing a patient on how to administer 0.5 mg of epinephrine intramuscularly. If the available dose is 0.5 mg/0.5 mL, how many mL should the patient be taught to administer?

Correct Answer is ["0.5"]

Explanation

The nurse is reviewing orders for a patient in anaphylactic shock. Which medications should the nurse plan to administer first?

Correct Answer is A

Explanation

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