Admission Assessment Day 1, 1000:

An older adult client was transferred to the ICU after they developed fever and hypotension. The client was initially admitted 4 days ago with a left hip fracture and subsequently underwent total left hip arthroplasty. The client is alert and oriented to person, place, and time. The client's partner is at the bedside.

Past Medical History: hypertension, congestive heart failure, Parkinson's disease

Allergies: penicillin (anaphylaxis)

Social History: Client has visual loss but didn't bring their glasses. The client is hard of hearing.

Hearing aids in place.

Which of the following actions should the nurse take? Select all that apply.

Explanation

C. Skin rash with fever

Stevens-Johnson syndrome (SJS) is a severe and potentially life-threatening hypersensitivity reaction that can occur as a rare side effect of certain medications, including allopurinol.

Monitoring and early recognition of SJS symptoms are crucial for prompt medical.

Skin rash with fever is a hallmark manifestation of Stevens-Johnson syndrome. It often starts with flu-like symptoms such as fever and malaise, followed by the appearance of a widespread, painful, and rapidly progressing rash. The rash typically involves the mucous membranes, including the mouth, nose, and eyes, and can be accompanied by blisters or sores. Prompt reporting of these symptoms is critical for early diagnosis and intervention.

Tinnitus with ear pain in (option A) is incorrect because it is not typically associated with Stevens- Johnson syndrome. It may indicate another condition or side effect unrelated to SJS.

Hyperreflexia, which refers to abnormally increased reflexes, in (option B) is incorrect because it is not a characteristic manifestation of Stevens-Johnson syndrome. It may indicate a neurological condition or reaction to another medication, but it is not specific to SJS.

Diplopia, or double vision, in option (D) is incorrect because it is not commonly associated with Stevens- Johnson syndrome. It may be caused by other ocular or neurological conditions.

In summary, the nurse should instruct the client taking allopurinol to monitor and report the manifestation of a skin rash with fever. This is important because it may indicate the development of Stevens-Johnson syndrome, a severe and potentially life-threatening reaction to the medication. Early recognition and medical intervention are crucial to minimize complications and ensure appropriate treatment.

The nurse should take the following actions when receiving a telephone prescription from a client's provider:

1. Ask the provider to spell out the name of the medication: This is important to ensure accurate transcription of the medication name. Spelling out the name helps prevent errors due to similar-sounding medications or confusion with abbreviations.
2. Request that the provider confirm the read-back of the prescription: This step ensures that the nurse and the provider are on the same page and that the prescription has been accurately transcribed. It allows for verification and correction if any discrepancies are identified.
3. Record the date and time of the telephone prescription: Documenting the date and time of the telephone prescription is essential for tracking and reference purposes. It helps establish a clear timeline of events and ensures proper documentation of the medication order.

It is not necessary to withhold the medication until the provider signs the prescription, as telephone prescriptions are typically followed up with a written prescription or electronic verification.

Instructing another nurse to record the prescription in the medical record may not be necessary, as the nurse who received the telephone prescription is responsible for accurately documenting the order in the medical record. However, if necessary, the nurse can delegate the task of documentation to another qualified staff member under their supervision, ensuring accuracy and completeness.