A client is receiving an IV infusion of an antibiotic. The client calls the nurse about feeling uneasy and uncomfortable owing to congestion. Which action by the nurse is most appropriate?
a. Elevate the head of the client's bed to 45 degrees.
b. Have another nurse call the Rapid Re-sponse Team.
c. Prepare to administer diphenhydramine (Benadryl).
d. Slow the rate of the IV infusion.
B
This client has early signs of anaphylaxis. The nurse must notify the Rapid Response Team but also needs to stay with the client in case of cardiovascular collapse. The nurse's best action is to ask another nurse to call the Team while he or she continues to assess the client. The nurse will prepare to administer epinephrine. Slowing the IV rate will not help the situation; if the client is reacting to the antibiotic, the nurse should change the IV tubing and solution. If the client is not hypotensive, the nurse can raise the head of the bed.
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