A nurse is preparing to administer an intradermal tuberculin test to a client. Which of the following actions should the nurse take?

A. Infection: Infection typically presents with redness, warmth, and purulent drainage at the IV site, not taut and edematous skin. Infiltration, however, can cause swelling and taut skin as the fluid is infused into the surrounding tissue rather than the vein.

B. Infiltration: Infiltration occurs when the IV fluid or medication leaks into the surrounding tissue. This results in swelling, taut, edematous skin, and sometimes discomfort. It is a common complication when the IV catheter is dislodged or not properly placed.

C. Air embolism: An air embolism is a rare but serious complication where air enters the bloodstream. Symptoms include chest pain, shortness of breath, and hypotension, but it does not cause the taut, edematous skin seen with infiltration.

D. Phlebitis: Phlebitis involves inflammation of the vein and is typically characterized by redness, warmth, pain, and swelling along the vein, not taut skin around the IV site. It can be caused by irritation from the IV catheter or the fluid being infused not a leak into tissues.

A. Heart rate: The client's heart rate increased significantly from 66/min to 104/min within 30 minutes of antibiotic administration. This tachycardia, especially in the context of other alarming symptoms, can indicate a compensatory mechanism for hypoperfusion due to vasodilation, a common feature of anaphylaxis.

B. Blood pressure: The client’s blood pressure has dropped significantly from 108/56 mm Hg to 88/56 mm Hg. Hypotension could be a sign of anaphylactic shock, especially considering the allergic symptoms (urticaria, swelling of the tongue).

C. Breath sounds: The presence of wheezing along with a drop in oxygen saturation (pulse oximetry 93%) is concerning for bronchospasm, which is common in allergic reactions or anaphylaxis. The client may need immediate airway management, including bronchodilators.

D. Urticaria: While urticaria (hives) is a classic sign of an allergic reaction, it is a skin manifestation and not as immediately life-threatening as airway compromise, hypotension, or a compensatory tachycardia.

E. Temperature: The temperature remains within a mild range (37.5°C/99.5°F to 37.6°C/99.7°F). It is slightly elevated but not concerning in the context of an allergic reaction. The temperature should be monitored but does not require immediate follow-up compared to the more critical findings.

F. Swollen tongue: Swelling of the tongue is a serious symptom of an allergic reaction and can lead to airway obstruction. Immediate intervention is required to prevent further complications, such as anaphylaxis, which can be life-threatening.