A nurse is caring for a client who is receiving ceftriaxone intravenously.
Which of the following manifestations should the nurse identify as an allergic reaction?
Polyuria.
Hypotension.
Nausea.
Bradycardia.
The Correct Answer is B
This is because hypotension (low blood pressure) can be a sign of anaphylaxis, which is a severe allergic reaction that can occur with ceftriaxone.

Choice A is wrong because polyuria (increased urination) is not a common sign of an allergic reaction to ceftriaxone.
Choice C is wrong because nausea can be a side effect of ceftriaxone but is not specific to an allergic reaction.
Choice D is wrong because bradycardia (slow heart rate) is not a common sign of an allergic reaction to ceftriaxone.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale:
Documenting the administration of the medication is crucial for maintaining accurate records and ensuring accountability. However, it is not the first action to take. The priority is to ensure the correct patient receives the correct medication.
Choice B rationale:
Identifying the client using two identifiers is the first and most critical step. This action ensures that the right patient receives the right medication, thereby minimizing the risk of medication errors.
Choice C rationale:
Comparing the amount of medication available to the inventory record is important for maintaining accurate inventory and preventing misuse or theft of controlled substances. However, this is not the first step in the process of administering medication to a patient in pain.
Choice D rationale:
Removing the medication from the medication dispensing cabinet is part of the process, but it should only be done after the patient has been properly identified to avoid any potential errors.
Correct Answer is C
Explanation
The correct answer is C. "I should stay upright for at least 15 minutes after taking this medication."
Choice A rationale:
Black stools are a common side effect of iron supplements and do not usually require notification of the provider unless accompanied by other symptoms such as pain or gastrointestinal bleeding.
Choice B rationale:
Iron supplements should not be taken with milk because calcium can interfere with the absorption of iron, reducing its effectiveness.
Choice C rationale:
Staying upright for at least 15 minutes after taking ferrous gluconate helps prevent the risk of esophageal irritation or discomfort, which indicates the client's correct understanding of this key instruction.
Choice D rationale:
Taking an antacid with ferrous gluconate is not recommended because antacids can interfere with the absorption of iron, reducing its efficacy.
Choice E rationale:
This is the same as Choice D and also incorrect for the same reason regarding the interaction between antacids and iron absorption.
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