A nurse is checking the forearm of a client who received a tuberculin skin test 48 hr ago. Which of the following findings at the injection site should indicate to the nurse a positive result?

• Shortness of breath. The client is experiencing respiratory distress, which could indicate a severe allergic reaction (anaphylaxis). Immediate intervention is needed to prevent airway compromise and respiratory failure.
• Intercostal retractions. Retractions occur when breathing is labored, suggesting airway obstruction or bronchoconstriction. This is a sign of worsening respiratory distress, requiring urgent medical attention.
• Wheezing auscultated throughout lung fields. Wheezing suggests bronchospasm, which is common in anaphylaxis and asthma attacks. The presence of diffuse wheezing indicates that the airways are narrowing, making breathing more difficult.
• Diffuse, raised rash present on trunk. A new-onset rash following antibiotic administration raises suspicion for anaphylaxis or a severe allergic reaction. Immediate treatment with antihistamines and corticosteroids may be required.
• Respiratory rate 30/min. The increased respiratory rate indicates that the client is compensating for airway constriction and hypoxia. This is an early warning sign of impending respiratory failure if not treated promptly.
• Blood pressure 90/55 mmHg. The drop in blood pressure suggests anaphylactic shock, where vasodilation and fluid leakage from capillaries lead to hypotension. Immediate administration of epinephrine is necessary to prevent cardiovascular collapse.
• Oxygen saturation 91% on room air. A decrease in oxygen saturation indicates impaired gas exchange, likely due to airway swelling and bronchospasm. Supplemental oxygen therapy should be provided to prevent further desaturation.

A. Promethazine. Promethazine is an antihistamine used to treat nausea, vomiting, and allergic reactions. It does not have antihypertensive properties and does not lower blood pressure. Instead, it has sedative effects and is commonly used for motion sickness or as a preoperative medication.

B. Amlodipine. Amlodipine is a calcium channel blocker that lowers blood pressure by relaxing blood vessels and improving blood flow. It is commonly prescribed for hypertension and angina, as it reduces vascular resistance and decreases the workload on the heart. Clients taking amlodipine should be monitored for hypotension, edema, and dizziness.

C. Fluconazole. Fluconazole is an antifungal medication used to treat fungal infections such as candidiasis. It does not affect blood pressure regulation and is not used for managing hypertension. However, it can interact with certain medications, so monitoring for drug interactions is important.

D. Phenazopyridine. Phenazopyridine is a urinary analgesic used to relieve symptoms of urinary tract infections (UTIs), such as burning and pain during urination. It does not lower blood pressure and has no effect on cardiovascular function. Clients should be advised that this medication can cause orange discoloration of the urine.