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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale:

The air bubble should not be expelled from the syringe before administering enoxaparin. The air bubble is included to ensure that the entire dose is administered and to help prevent leakage of the medication into the subcutaneous tissue, which can reduce bruising.

Choice B rationale:

After administering enoxaparin, applying firm pressure (but not massaging) to the injection site helps minimize bruising and bleeding. It's important not to massage the site as this can increase the risk of bleeding.

Choice C rationale:

The needle should be inserted fully into the subcutaneous tissue at a 90-degree angle (or at a 45-degree angle if the client has little subcutaneous tissue). Inserting the needle halfway may result in improper administration.

Choice D rationale:

Enoxaparin is a low-molecular-weight heparin that should be administered subcutaneously, not intramuscularly. Administering it intramuscularly could increase the risk of bleeding and is not the appropriate route for this medication.

A. Limit foods containing tyramine. B. Decrease your daily sodium intake. C. Take this medication 2 hours before a meal. D. Report swelling of the feet to your provider.

Correct Answer is D

Explanation

This is because swelling of the feet can be a sign of lithium toxicity, which is a serious condition that can occur when the level of lithium in the blood is too high. Lithium toxicity can cause confusion, irregular heartbeat, muscle weakness, and kidney problems. Therefore, the client should report any signs of lithium toxicity to their provider as soon as possible.

Choice A is wrong because limiting foods containing tyramine is not necessary for clients taking lithium. Tyramine is a substance found in some foods that can interact with certain antidepressants called monoamine oxidase inhibitors (MAOIs), but not with lithium.

Choice B is wrong because decreasing the daily sodium intake can actually increase the risk of lithium toxicity.

Sodium helps to regulate the amount of lithium in the body, so if the sodium level is low, the lithium level can rise too high.

The client should maintain a normal sodium intake and drink enough fluids while taking lithium.

Choice C is wrong because taking this medication 2 hours before a meal is not required for clients taking lithium.

Lithium can be taken with or without food, but it should be taken at the same time each day to keep a steady level in the blood.

Taking lithium 2 hours before a meal may cause stomach upset, which is a common side effect of lithium.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 preparing to administer enoxaparin to a client. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is providing teaching to a client who has a new prescription for lithium carbonate. Which of the following instructions should the nurse include?

Correct Answer is D

Explanation

A nurse is caring for a client who is taking tamoxifen to treat breast cancer. The nurse should identify which of the following manifestations as an adverse effect of this medication?

A nurse is caring for a client who has breast cancer and reports pain 1 hr after administration of prescribed morphine 10 mg IV. Which of the following medications should the nurse expect to administer?

A nurse is preparing to initiate IV therapy for a client. Which of the following sites should the nurse use to place the peripheral IV catheter?

A nurse recently administered filgrastim intravenously to a client who has cancer and is receiving cytotoxic chemotherapy. For which of the following data, discovered after the medication was administered, should the nurse file an incident report?

A nurse is assessing a client after administering phenytoin IV bolus for a seizure. Which of the following findings should the nurse identify as an adverse effect of this medication?

A nurse is assessing a client who is receiving a peripheral IV infusion and notes infiltration of fluid into the tissues surrounding the insertion site. Which of the following actions should the nurse take?

A nurse is caring for a client who has hyponatremia and is receiving an infusion of a prescribed hypertonic solution. Which of the following findings should indicate to the nurse that the treatment is effective?

A nurse is teaching a guardian of a school-age child who has a new prescription for a fluticasone metered-dose inhaler. Which of the following information should the nurse include in the teaching? (Select all that apply)

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?