The patient’s vital signs are as follows: Temperature 97.5 F (36.4 C), Heart rate 104 beats/minute, Respirations 29 breaths/minute, Blood pressure 119/82 mm Hg, Oxygen saturation 89%. Oxygen mask applied.
What should the nurse do next?

Choice A rationale:

It is true that antibiotics are not effective against viruses like influenza. They only work against bacteria.

However, while providing this information to the client is accurate, it does not directly address the client's inquiry about taking oseltamivir, which is an antiviral medication.

It's essential for the nurse to guide the client toward the appropriate healthcare provider who can assess the client's condition and make an informed decision about whether oseltamivir is a suitable treatment option.

Choice B rationale:

While it is true that influenza vaccination is most effective when given before exposure to the virus, it is still a relevant consideration even after symptoms have begun.

Studies have shown that antiviral medications like oseltamivir can potentially reduce the severity and duration of influenza symptoms, even when started within 48 hours of symptom onset.

Therefore, simply advising the client that it's too late for vaccination without exploring other potential treatment options would be incomplete and potentially disadvantageous to the client's care.

Choice C rationale:

This is the most appropriate response because it ensures that the client receives a comprehensive assessment and individualized treatment plan from a qualified healthcare provider.

The provider can evaluate the client's symptoms, medical history, and potential risk factors to determine if oseltamivir is a suitable medication.

Additionally, the provider can discuss other potential treatment options, such as over-the-counter medications for symptom relief, and provide guidance on self-care measures to promote recovery.

Choice D rationale:

While over-the-counter medications can help manage some symptoms of influenza, such as fever, aches, and cough, they do not directly target the virus itself.

Antiviral medications like oseltamivir can potentially shorten the duration of the illness and reduce the risk of complications, especially in individuals at higher risk.

Therefore, relying solely on over-the-counter medications without considering antiviral therapy could potentially delay recovery and increase the likelihood of adverse outcomes.

Choice A rationale:

Autoimmune responses occur when the immune system mistakenly attacks the body's own tissues. They are not typically triggered by allergens like bee stings.

Autoimmune responses often develop slowly over time and present with symptoms related to the specific tissues being attacked.

The rapid onset of symptoms in this case, along with the specific symptoms of rash, shortness of breath, and low blood pressure, are not characteristic of an autoimmune response.

Choice B rationale:

Type II hypersensitivity reactions involve antibodies that target and destroy cells or tissues. These reactions often take hours or days to develop, rather than minutes.

Examples of type II hypersensitivity reactions include transfusion reactions, hemolytic disease of the newborn, and some autoimmune diseases.

The rapid onset of symptoms in this case is not consistent with a type II hypersensitivity reaction.

Choice C rationale:

Cell-mediated hypersensitivity reactions involve T cells that directly attack cells or tissues. These reactions typically take 1-3 days to develop.

Examples of cell-mediated hypersensitivity reactions include contact dermatitis (e.g., poison ivy), graft-versus-host disease, and some drug reactions.

The rapid onset of symptoms in this case, as well as the specific symptoms of rash, shortness of breath, and low blood pressure, are not characteristic of a cell-mediated hypersensitivity reaction.

Choice D rationale:

IgE response hypersensitivity reactions are the most immediate type of allergic reaction.

They are mediated by immunoglobulin E (IgE) antibodies, which bind to mast cells and basophils.

When an allergen (like bee venom) cross-links IgE antibodies on mast cells, it triggers the release of histamine and other inflammatory mediators.

These mediators cause vasodilation, increased vascular permeability, smooth muscle contraction, and mucus secretion, leading to the characteristic symptoms of an allergic reaction.

The rapid onset of symptoms in this case, including rash, shortness of breath, and low blood pressure, are consistent with an IgE-mediated hypersensitivity reaction.