Practice Question
A nurse is caring for a client who has streptococcal pneumonia and a prescription for penicillin G by intermittent IV bolus. 10 minutes into the infusion of the third dose, the client reports that the IV site itches and that he feels dizzy and short of breath. Which of the following actions should the nurse take first?
Answer Choices:
Correct Answer:
Stop the infusion.
Rationale:
🔷 Stopping the infusion immediately is the priority because the client is showing signs of a possible anaphylactic reaction, including itching at the IV site, dizziness, and shortness of breath.
🔷 Continuing the medication can worsen the hypersensitivity response, leading to bronchospasm, hypotension, and cardiovascular collapse.
🔷 After stopping the infusion, the nurse can maintain IV access with normal saline to allow for emergency medication administration (e.g., epinephrine, antihistamines).
🔷 The other interventions, such as auscultating breath sounds or notifying the provider, are appropriate but must follow immediate discontinuation of the offending agent.
🔷 Early recognition and stopping the trigger medication are key to preventing severe complications.
Want to practice more questions like this?
This question is from Custom: N303 Final 7/06 which contains 59 questions.
More Questions from This Exam
A nurse is caring for a client who has difficulty swallowing medications and is prescribed enteric-coated aspirin PO once daily. The client asks if the medication can be crushed to make it easier to swallow. Which of the following responses should the nurse provide?
Answer Choices:
A nurse is completing a medication history for a client who reports using calcium carbonate antacid. Which of the following recommendations should the nurse make about taking this medication?
Answer Choices:
A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?
Answer Choices:
A nurse is caring for a client who has acute respiratory distress syndrome (ARDS), and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes?
Answer Choices:
A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make?
Answer Choices:
Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN Custom Exam(s)
- Answer Choices: 4