A nurse started a client's gentamicin via an intravenous (IV) route that is programmed to infuse over one hour.
Ten minutes after the administration, the client reports dyspnea, generalized rash, and itchiness.
What is the priority intervention for this client?
Stop the infusion immediately.
Administer an IV fluid bolus to flush the medication.
Encourage the client to take deep breaths and remain calm.
Administer oxygen via nasal cannula.
The Correct Answer is A
Choice A rationale
Stopping the infusion immediately is crucial to prevent further exposure to the allergen causing the adverse reaction. This intervention halts the administration of gentamicin, which is likely causing the dyspnea, rash, and itchiness. Prompt discontinuation of the medication minimizes the severity of the allergic reaction and allows for further medical management.
Choice B rationale
Administering an IV fluid bolus to flush the medication is not the priority intervention in this case. While it might help to clear the medication from the bloodstream, it does not address the immediate need to stop the allergen exposure and manage the allergic reaction.
Choice C rationale
Encouraging the client to take deep breaths and remain calm is supportive, but it does not address the root cause of the allergic reaction, which is the administration of gentamicin. The immediate priority is to stop the infusion and then manage the symptoms.
Choice D rationale
Administering oxygen via nasal cannula may help alleviate respiratory distress, but it is not the priority intervention. The primary step is to stop the infusion to prevent further exposure to the allergen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale
Sucralfate (Carafate) acts by forming a viscous, adhesive substance that binds to the ulcer site, creating a physical barrier protecting it from stomach acid and allowing healing.
Choice A rationale
Sucralfate does not function as an endogenous prostaglandin; it does not mimic or enhance prostaglandin activity in the GI tract.
Choice C rationale
Sucralfate does not neutralize gastric acid; that is the function of antacids.
Choice D rationale
Sucralfate does not antagonize H2 receptors on parietal cells; H2 receptor antagonists are a different class of medication.
Correct Answer is A
Explanation
Choice A rationale
Losartan is an angiotensin II receptor blocker (ARB) that helps lower blood pressure by relaxing blood vessels. It is often prescribed for clients who cannot tolerate angiotensin-converting enzyme (ACE) inhibitors like Captopril or Lisinopril due to side effects such as a persistent cough.
Choice B rationale
Digoxin is a medication primarily used to treat heart failure and atrial fibrillation. It is not typically prescribed for the management of hypertension as it does not directly lower blood pressure.
Choice C rationale
Captopril is an ACE inhibitor that can cause a persistent cough in some patients. Since the client has experienced this side effect, it is unlikely that Captopril would be prescribed again.
Choice D rationale
Lisinopril is another ACE inhibitor, similar to Captopril. Given the client's history of a cough caused by ACE inhibitors, Lisinopril is also not a suitable option.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.