The nurse is performing a physical assessment on a patient who is receiving treatment with abacavir, zidovudine, and lamivudine (Trizivir). The patient complains of fatigue
Upon further assessment, the nurse finds a rash and notes that the patient has a temperature of 101.1° F. What is the nurse's best course of action?
a. Tell the patient that this is an expected response to these medications and to continue the agents as prescribed.
b. Have the patient hold the medications and arrange for an immediate evaluation by the prescriber.
c. Have the patient continue the abacavir but discontinue the other two agents for 3 weeks.
d. Instruct the patient to continue all three medications and administer an antihistamine for the symptoms.
ANS: B
The patient should discontinue all the medications. Immediate assessment by the provider is required, because the patient is showing early symptoms of a fatal hypersensitivity reaction. This is not an expected response; it indicates a serious reaction, which the patient should report to the prescriber immediately. The patient should not continue the medications for any additional dosages.
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