A woman has been prescribed a daily Benadryl for allergy symptoms by her health care provider. She recently began have difficulty staying awake at work, most likely this is related to the Benadryl. Which of the following best describes this response?

Leaving medication at the client's bedside is unsafe as it can lead to medication errors, missed doses, or accidental ingestion.
B. Coming back in a few minutes to administer the medication respects the client’s therapy schedule and ensures the nurse can directly observe the client taking the medication, ensuring proper administration and adherence.
C. Preparing the medication in the medication room ahead of time can be efficient but doesn’t address the need to personally administer the medication and confirm the client takes it.
D. Documenting the medication was given without actually administering it is unethical and against best practices as it assumes the client will take the medication without verification.

A. Bilateral breath sounds clear and present throughout at 1600 are normal findings and do not require immediate follow-up.
B. The temperature at both 1600 (37.6°C) and 1630 (37.5°C) is slightly elevated but not critically high. It does not require immediate follow-up unless it worsens significantly or is accompanied by other concerning symptoms.
C. Urticaria (hives) over the chest and trunk, along with itching and difficulty swallowing (dysphagia), are signs of an allergic reaction, which requires immediate follow-up and assessment.
D. The blood pressure decreased to 78/52 mm Hg at 1630 from 110/58 mm Hg at 1600. This significant drop indicates hypotension and requires immediate follow-up.
E. Difficulty swallowing (dysphagia) reported by the client suggests a potential airway compromise and requires immediate follow-up to assess the severity and intervene accordingly.