A nurse is caring for a client who develops an anaphylactic reaction to IV antibiotic administration.
After assessing the client’s respiratory status and stopping the medication infusion, which of the following actions should the nurse take next?
Administer epinephrine IM.
Replace the infusion with 0.9% sodium chloride.
Give diphenhydramine IM.
Elevate the clients legs and feet.
The Correct Answer is A
Epinephrine (adrenaline) is the first-line treatment for anaphylaxis, a severe and potentially life-threatening allergic reaction. Epinephrine works by reducing the body’s allergic response and improving the breathing and circulation of the client. Epinephrine should be given as soon as possible after the onset of anaphylaxis symptoms, using an auto-injector device if available.
Choice B is wrong because replacing the infusion with 0.9% sodium chloride (normal saline) is not enough to treat anaphylaxis. Normal saline can help maintain the blood pressure and hydration of the client, but it does not reverse the allergic reaction or improve the breathing of the client. Normal saline can be given after epinephrine, but not before or instead of it.
Choice C is wrong because giving diphenhydramine IM is not enough to treat anaphylaxis. Diphenhydramine is an antihistamine that can help relieve some of the symptoms of anaphylaxis, such as itching and hives, but it works too slowly and does not address the more serious effects of anaphylaxis on the breathing and circulation of the client. Diphenhydramine can be given after epinephrine, but not before or instead of it.
Choice D is wrong because elevating the client's legs and feet is not enough to treat anaphylaxis. Elevating the legs and feet can help increase the blood flow to the vital organs, but it does not reverse the allergic reaction or improve the breathing of the client. Elevating the legs and feet can be done after epinephrine, but not before or instead of it.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This is the priority for the nurse to report to the provider because cefuroxime is a cephalosporin antibiotic that can cause serious or life-threatening allergic reactions in people who are allergic to penicillin. The nurse should not administer cefuroxime to this client until the provider is notified and an alternative antibiotic is prescribed.
Choice A is wrong because the client has a BUN level of 18 mg/dL, which is within the normal range of 7 to 20 mg/dL.
This does not indicate any renal impairment or adverse reaction to cefuroxime.
Choice B is wrong because the client reports a history of nausea with cefuroxime, which is a common side effect of this drug.
The nurse should instruct the client to take cefuroxime with food to reduce nausea, but this is not a priority to report to the provider.
Choice D is wrong because the client takes aspirin daily, which does not interact with cefuroxime.
The nurse should monitor the client for any signs of bleeding or bruising while taking aspirin, but this is not a priority to report to the provider.
Correct Answer is ["A","B"]
Explanation
Fluticasone is an inhaled steroid that prevents the symptoms of asthma by decreasing inflammation in the airways. It is not used to treat a sudden asthma attack.
Some additional information to explain why the other choices are wrong are:
Choice C is wrong because soaking the inhaler in water after use can damage the device and affect its performance.
Choice D is wrong because fluticasone is not a rescue inhaler that can be used as needed for shortness of breath.It is a controller inhaler that should be used regularly as prescribed by the doctor.
Choice E is wrong because shaking the device prior to administration is not necessary for a fluticasone metered-dose inhaler (MDI).However, it is recommended for fluticasone inhalation powder (Flovent Diskus). Some normal ranges that may be applicable are:
The usual dose of fluticasone MDI for adults and children 12 years and older is 55 to 232 mcg twice a day.The usual dose of fluticasone MDI for children 4 to 11 years old is 30 mcg twice a day. The maximum dose of fluticasone MDI for adults and children 12 years and older is 1000 mcg twice a day.
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