A nurse is caring for a client who has streptococcal pneumonia and a prescription for penicillin Gby intermittent IV bolus. 10 minutes into the infusion of the third dose, the client reports that the IV site itches and that he feels dizzy and short of breath. Which of the following actions should the nurse take first?
Call the client's provider.
Stop the infusion.
Auscultate the client's breath sounds.
Elevate the head of the bed.
Elevate the head of the bed.
The Correct Answer is B
The client is exhibiting symptoms and signs of anaphylaxis. Anaphylaxis is a severe systemic allergic reaction that occurs due to allergens presenting with (itching) urticaria and sudden onset shortness of breath and/or shock. The first action should be to stop the infusion to prevent worsening the severity of the allergic reaction.
A. Important to allow for further prescription but not a priority
C. Auscultating the lungs allows the nurse to assess for the severity of the reaction but should come after stopping the infusion
D. Elevating the head can improve ventilation but is not a priority
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Spironolactone is a potassium-sparing diuretic used in the management of ascites associated with liver failure. Its mechanism of action includes blocking the actions of aldosterone, a hormone that promotes sodium retention and potassium excretion in the kidneys. This results in increased urinary sodium excretion and hyponatremia and hyperkalemia.
A. Decreased chloride level is not typically associated with spironolactone use.
C. Spironolactone is a potassium-sparing diuretic, so it leads to an increased potassium level (hyperkalemia)
D. Spironolactone is not associated with decreased phosphate levels.
Correct Answer is D
Explanation
Status asthmaticus is an acute, life threatening exacerbation of asthma causes by bronchospasm on exposure to a trigger. Status asthmaticus can lead to respiratory failure. Short acting beta 2 agonists bind to beta 2 receptors on the airway epithelium causing bronchodilation and promotes air flow. They are used as first line due to their short onset of action.
A. Administering an inhaled glucocorticoid is used for long term control of inflammation in asthma but has no role in acute attacks
B. Identification of triggers is important but not a priority in status asthmaticus.
C. Obtaining a peak flow reading is useful but not a priority.
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