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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

The correct answer is choice C. Keep the tablets at room temperature in their original glass bottle. Rationales: Choice A rationale: Taking one tablet each morning 30 minutes prior to eating is incorrect. Sublingual nitroglycerin is used to relieve acute angina attacks and is taken as needed rather than on a fixed schedule. Choice B rationale: Discarding any tablets not used every 6 months is incorrect. Sublingual nitroglycerin tablets should be replaced every 6 months to ensure potency, but this is not the main teaching point for safe storage. Choice C rationale: Keeping the tablets at room temperature in their original glass bottle is correct. Nitroglycerin tablets are sensitive to light and moisture, and the original glass bottle protects them from these elements, ensuring their effectiveness. Choice D rationale: Placing the tablet between the cheek and gum to dissolve is incorrect. Sublingual nitroglycerin tablets should be placed under the tongue where they dissolve and are absorbed quickly into the bloodstream for rapid relief of angina symptoms

Correct Answer is ["0.4"]

Explanation

To calculate the amount of heparin to administer, use the formula:

mL of heparin=units available units ordered×1mL available

Substituting the values given in the question, we get:

mL of heparin=100004000×11=0.4

Therefore, the nurse should administer 0.4 mL of heparin.

Normal ranges for heparin therapy vary depending on the condition being treated and the laboratory method used to measure APTT.

A general range is 60 to 80 seconds or 1.5 to 2.5 times the control value.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has angina about a new prescription for sublingual nitroglycerin tablets. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

Correct Answer is ["0.4"]

Explanation

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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?