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 A
Explanation
Fat overload syndrome is a rare but serious complication that can occur in clients receiving lipid infusion. It is typically characterized by fever.
Although spontaneous hemorrhage can occur, peripheral edema is not a typical feature of fat overload syndrome.
Hypertension is not a typical feature of fat overload syndrome. However, hypotension may occur due to fluid shift and vasodilation.
Erythema can occur at the site of infusion during lipid infusion. However, it is not a typical feature of fat overload syndrome.
Correct Answer is C
Explanation
Warfarin is a coumarin anticoagulant that has potential to increase the risk of bleeding. When taken during pregnancy, warfarin causes fetal bleeding. Warfarin is also teratogenic and it causes various birth defects including skeletal abnormalities, hypoplastic nose, intellectual disabilities and deafness hence it's contraindicated. Pregnant women who require anticoagulation are put of heparin in the place of warfarin to prevent these complications.
A. B, D - are not contraindications for warfarin use.
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