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?

This is because it uses the full name of the drug, the exact dose, the route of administration, the frequency, and the indication for use. It also avoids any abbreviations that could be confused with other drugs or measurements.

Choice B is wrong because MS is an abbreviation for morphine sulfate which could be mistaken for magnesium sulfate.

Choice C is wrong because MSO4 is an abbreviation for morphine sulfate that could be mistaken for magnesium sulfate.

Choice D is wrong because 6.0 mg could be misread as 60 mg and lead to a tenfold overdose.

Normal ranges for morphine dosage depend on the route of administration, the indication, and the patient’s tolerance and response.

For acute pain, the usual oral dose is 10 to 30 mg every 4 hours as needed. For chronic pain, the usual oral dose is 15 to 30 mg every 8 to 12 hours as needed.

For intravenous (IV) administration, the usual dose is 2.5 to 15 mg every 4 hours as needed.

The morphine equivalent daily dose (MEDD) is a concept that attempts to establish an equivalency in terms of dose when comparing any opioid to morphine.

This is because a weight gain of 2.5 kg (5 Ib) in 2 days indicates a worsening of heart failure and fluid retention, which may require an adjustment of the diuretic dose or other medications.

The provider should be informed of this change as soon as possible to prevent further complications.

Choice A is wrong because teaching the client about foods low in sodium is not the first action the nurse should take.

While a low-sodium diet is important for heart failure patients, it is not an urgent intervention and it does not address the immediate problem of fluid overload.

Choice B is wrong because determining medication adherence by the client is not the first action the nurse should take.

While it is important to assess if the client is taking furosemide as prescribed, it is not an urgent intervention and it does not rule out other causes of fluid retention, such as renal impairment or disease progression.

Choice C is wrong because encouraging the client to dangle the legs while sitting in a chair is not the first action the nurse should take.

While this may help reduce edema in the lower extremities, it does not address the underlying cause of fluid overload and it may worsen pulmonary congestion by increasing venous return to the heart.