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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Medicate the client 30 minutes before the procedure. This is the correct action. Administering pain medication 30 minutes before the procedure allows the medication to take effect and provides pain control during the procedure.
Choice B rationale
Reassure the client that the procedure is not painful. This is not accurate. Debridement and hydrotherapy can be painful, so it’s important to manage the client’s pain effectively.
Choice C rationale
Utilize meditation and imagery. While these techniques can be helpful adjuncts to pain management, they should not replace pharmacological pain management in this situation.
Choice D rationale
Administer pain medication around the clock. While it’s important to manage pain effectively, this does not specifically address the client’s needs during the hydrotherapy and debridement procedure.
Correct Answer is ["A","B","C","G"]
Explanation
Choice A rationale
Contact with infected blood or bodily fluids is a major risk factor for Hepatitis B. The virus is present in the blood and bodily fluids of infected individuals and can be transmitted through direct contact.
Choice B rationale
Unprotected sex is a significant risk factor for Hepatitis B. The virus can be transmitted through sexual contact with an infected person.
Choice C rationale
Sharing dirty needles is a well-known risk factor for Hepatitis B. This is particularly a concern among individuals who inject drugs.
Choice D rationale
Sharing eating utensils is not typically a risk factor for Hepatitis B. The virus is not usually transmitted through casual contact or sharing of utensils.
Choice E rationale
Contact with contaminated food or water is not a risk factor for Hepatitis B. The virus is not transmitted through food or water.
Choice F rationale
Exposure to chemicals or toxins is not a risk factor for Hepatitis B. While certain chemicals and toxins can damage the liver, they do not directly cause Hepatitis B3.
Choice G rationale
Contact with infected feces is not typically a risk factor for Hepatitis B. The virus is primarily transmitted through blood and bodily fluids, not fecal matter.
Choice H rationale
Heavy alcohol consumption is not a direct risk factor for Hepatitis B. However, it can contribute to liver damage and complicate the course of the disease if a person is infected.
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