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 B

Explanation

This is because fever is a common sign of an acute infusion reaction that can occur when receiving IV amphotericin B. An acute infusion reaction is caused by the release of pro-inflammatory cytokines from the fungal cell wall disruption by amphotericin B. It usually occurs within the first hour of infusion and can be prevented by administering pre-medications such as antipyretics, antihistamines, or corticosteroids.

Choice A. Pedal edema is wrong because it is not a typical sign of an acute infusion reaction.

Pedal edema may indicate fluid overload, heart failure, or renal impairment, which are not directly related to amphotericin B infusion.

Choice C. Dry cough is wrong because it is not a typical sign of an acute infusion reaction.

Dry cough may indicate an allergic reaction, pulmonary infection, or interstitial lung disease, which are not directly related to amphotericin B infusion. Choice D. Hyperglycemia is wrong because it is not a typical sign of an acute infusion reaction.

Hyperglycemia may indicate diabetes mellitus, steroid use, or stress response, which are not directly related to amphotericin B infusion.

A. Plan to self-administer this medication for the next 6 months. B. Administer the medication into one nostril once per week. C. Lie down for 1 hour after administering the medication. D. Use a nasal decongestant 15 minutes before the medication if you have a stuffy nose.

Correct Answer is B

Explanation

This is the recommended dosage for cyanocobalamin nasal spray for pernicious anaemia and vitamin B12 deficiency. Cyanocobalamin nasal gel is used to prevent a lack of vitamin B12 that may be caused by various factors.

Choice A is wrong because the duration of treatment depends on the individual’s response and blood levels of vitaminB. Some people may need to use this medication for longer than 6 months.

Choice C is wrong because there is no need to lie down for 1 hour after administering the medication.

This may cause nasal irritation or drainage.

Choice D is wrong because using a nasal decongestant 15 minutes before the medication may interfere with the absorption of cyanocobalamin. If you have a stuffy nose, you should talk to your doctor about alternative ways to take vitaminB.

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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 monitoring for an infusion reaction for a client who is receiving a dose of IV amphotericin B. Which of the following findings should indicate to the nurse that the client is experiencing an acute infusion reaction?

Correct Answer is B

Explanation

A nurse is teaching a client who has pernicious anemia to self-administer nasal cyanocobalamin. Which of the following information should the nurse include in the teaching?

Correct Answer is B

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?