A nurse is collecting data from a client who has a new prescription for amoxicillin.
Which of the following findings indicates that the client is having an allergic reaction to the medication?

Choice A rationale:

The gauge and length of needle used for an IM injection are important to document. This information can help track which supplies were used and can be useful for future reference.

Choice B rationale:

While it’s important to check the medication expiration date before administration, it’s not typically documented after administering medication.

Choice C rationale:

The dose of medication administered should always be documented. This helps ensure accurate medical records and allows healthcare providers to track how much of a medication a patient has received.

Choice D rationale:

The site of injection should be documented. This can help prevent complications such as repeated use of the same injection site.

Choice E rationale:

The time of administration should be documented. This helps keep track of when the patient received their medication, which is crucial for medications that need to be given at specific intervals.

Choice A rationale:

Hanging the antibiotic medication bag above the level of the primary infusion is an important step in administering an antibiotic via intermittent IV bolus. However, it is not the first step. The medication bag is usually hung higher to allow the antibiotic to infuse by gravity once it’s connected.

Choice B rationale:

Wiping the connection port of the primary IV tubing with an antiseptic swab is a crucial step in preventing infection. However, this is typically done just before connecting the secondary line, not as the first step.

Choice C rationale:

Checking the IV site for signs of infiltration is indeed the first step. It’s important to ensure that the IV catheter is still properly placed in the vein and that there are no signs of infection or infiltration, which could cause complications.

Choice D rationale:

Connecting the tubing of the medication bag to the primary tubing is done after cleaning the port and before hanging the bag. It’s not the first step.