The nurse cares for a client who had an angiogram of the aorta with a contrast medium about 4 hours ago. Which is the priority client assessment for the nurse to monitor for early detection of delayed allergic reactions?
1. Pallor
2. Pruritus
3. Dyspnea
4. Cool skin
3
3. The nurse monitors the client respiratory status for an early indication of a delayed hypersensitivity reaction to the dye. Other clinical indicators include flushing, itching, and urticaria.
1. Pallor is usually an indicator of altered cardiovascular status.
2. Pruritus is an indication of allergic reactions; however, it is not as high on the client's hierarchy of needs as breathing.
4. Cool skin potentially occurs with a delayed allergic reaction; however, breathing is higher on the client's hierarchy of needs than cardiovascular status.
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