The nurse administers a medication to the patient.
Which symptoms indicate that the patient is having an allergic reaction rather than a side effect?

Rationale for Choice A:

Incorrect. While the patient is experiencing an allergic reaction, it is not moderate. The presence of difficulty breathing and a drop in blood pressure are signs of a severe, life-threatening anaphylactic reaction.

Anaphylaxis is a severe, rapid-onset allergic reaction that can lead to death if not treated promptly. It typically involves multiple body systems, including the skin, respiratory system, cardiovascular system, and gastrointestinal system.

Moderate allergic reactions typically present with localized symptoms such as hives, itching, and redness. They do not typically involve respiratory or cardiovascular compromise.

Rationale for Choice B:

Incorrect. The patient's symptoms are not consistent with food poisoning. Food poisoning typically causes gastrointestinal symptoms such as nausea, vomiting, diarrhea, and abdominal cramps. It does not typically cause hives, difficulty breathing, or a drop in blood pressure.

The timing of the symptoms, occurring 2 hours after receiving an antibiotic, strongly suggests an allergic reaction to the medication.

Rationale for Choice C:

Correct. The patient's symptoms are consistent with anaphylaxis, a severe allergic reaction that requires immediate emergency treatment.

Key features of anaphylaxis include:

Skin involvement (hives, itching, flushing, swelling)

Respiratory distress (difficulty breathing, wheezing, tightness in the chest) Cardiovascular compromise (drop in blood pressure, lightheadedness, fainting) Gastrointestinal symptoms (nausea, vomiting, diarrhea)

Swelling of the tongue or throat

Rationale for Choice D:

Incorrect. The patient's reaction is not mild and cannot be treated with an antihistamine alone. Antihistamines are effective for mild allergic reactions, but they are not sufficient to treat anaphylaxis.

Anaphylaxis requires immediate treatment with epinephrine, which is a life-saving medication that can reverse the effects of the allergic reaction.

Choice A rationale:

Irrigating with sterile saline before swabbing can dilute the wound specimen and reduce the accuracy of the culture results. This is because the saline can wash away some of the bacteria that are present in the wound, making it more difficult to identify the specific bacteria that are causing the infection.

Additionally, swabbing the center of the wound may not collect a representative sample of the bacteria present, as bacteria can often be found in higher concentrations at the edges of the wound. This is because the edges of the wound are often where the tissue is most damaged and where the bacteria are able to enter the body more easily.

Choice B rationale:

Obtaining a sample of the drainage from the dressing on the wound may not be as accurate as collecting a sample directly from the wound. This is because the drainage may contain bacteria from the surrounding skin or environment, which could contaminate the culture results.

Additionally, the drainage may not contain a representative sample of the bacteria present in the wound, as some bacteria may not be able to drain out of the wound.

Choice D rationale:

Collecting a tissue sample from the wound during a surgical procedure is the most accurate way to obtain a culture. However, this is not always feasible or necessary.

It is often possible to obtain an accurate culture by collecting a sample from the wound using a sterile swab. This is a less invasive procedure and can be done at the bedside.