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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale- Levothyroxine is a synthetic form of thyroxine. It is used to provide the body with thyroxine to sustain basal metabolism in cases of hypothyroidism. An overdose of the medication causes symptoms which include insomnia, hyperactive tendon reflexes, diarrhea and anxiety
A, B, D- features of hypothyroidism
Correct Answer is A
Explanation
After a pneumonectomy, positioning the client on the nonoperative side helps maximize ventilation to the remaining lung and facilitates drainage of secretions. Placing the client on the nonoperative side allows for better perfusion and ventilation of the remaining lung, which can improve oxygenation and respiratory function.
B-sims position is used during insertion of suppository of a rectal exam
C -Semi-Fowler's position is used in clients with heart failure and pulmonary edema to promoted ventilation in the upper lungs
D-Prone position is used during surgical procedures involving the back in the operating room
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