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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Related Questions
Correct Answer is C
Explanation
Montelukast is a leukotriene receptor antagonist used for the long-term control of asthma. Among the side effects, montelukast causes drowsiness and hence should be taken at night before bed to avoid interference with daily activities.
A. Montelukast is an oral preparation that does not require a spacer unlike inhalers such as salbutamol
B. Montelukast is used controller therapy rather than a reliever in acute asthmatic attack
D. Rinsing the mouth is relevant in the use of inhaled corticosteroids to prevent oral thrush but not montelukast.
Correct Answer is A
Explanation
Phenytoin is a lifelong medication for clients presenting with unprovoked seizures. The statement shows that the client has not understood their current management plan or is in denial and requires further counselling to promote adherence.
B.Notifying the doctor before taking any other medication is important as certain drug interactions can lead to toxicity of inadequate blood levels of phenytoin.
C.This is correct as it shows understanding that phenytoin can cause oral adverse effects such as gingival hyperplasia
D.Shows understanding that some drug preparations could have incipient that may cause adverse effects that the originally tolerated agent
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