The practical nurse (PN) is caring for a client with a new prescription for fluticasone furoate nasal spray, a glucocorticoid prescribed for the client's nasal allergy symptoms. In reinforcing instructions about self-administration of the nasal spray, the PN should emphasize the need for the client to take which action before self-administration?

Hives (also known as urticaria) are raised, red, itchy welts on the skin that can be caused by an allergic reaction to medication, including antibiotics. It is essential for the PN to recognize this potentially severe allergic reaction and take immediate action.

Immediate action steps include:

1. Stop the infusion of the intravenous antibiotic immediately.
2. Notify the healthcare provider and report the allergic reaction.
3. Assess the client's airway, breathing, and circulation to ensure there are no signs of respiratory distress or anaphylaxis.
4. Administer prescribed emergency medications if needed (e.g., epinephrine, antihistamines).
5. Monitor the client closely for any further signs of an allergic reaction or anaphylaxis.

The other assessment findings mentioned are also important to address, but they do not require immediate action:

A- Dry mouth with thirst: This may indicate dehydration, which should be addressed by encouraging the client to drink fluids, but it does not pose an immediate threat to the client's safety.

B- Warm skin with elastic turgor: This suggests that the client is adequately hydrated, and the skin's elasticity is normal, which is a positive finding.

C- Low-grade fever with diaphoresis: A low-grade fever indicates a mild elevation in temperature, and diaphoresis (sweating) may be the body's response to regulate temperature. The PN should monitor the client's temperature and assess for other signs of infection, but this finding does not require immediate action

Antiplatelet medications, such as aspirin or clopidogrel, are prescribed to prevent the formation of blood clots by inhibiting platelet aggregation. These medications can increase the risk of bleeding or prolonged bleeding time. Therefore, when removing the saline lock, applying pressure over the site for several minutes helps to minimize the risk of bleeding and promote hemostasis.
A. Leaving the saline lock in place and notifying the charge nurse may not be necessary unless there are specific concerns or complications related to the client's condition.
C. Encouraging the client to drink additional oral fluids is not directly related to the discontinuation of the saline lock and the potential risk of bleeding associated with antiplatelet medication.
D. Preparing a warm pack to apply after removing the lock is not necessary for this situation. Warm packs are typically used for comfort or to promote circulation, but they are not directly related to the risk of bleeding associated with antiplatelet medication.