The client is to receive an injection of penicillin G benzathine (Bicillin LA) in the outpatient clinic. What is a priority nursing action by the nurse prior to administering this injection?
1. Have the client lie down and assess vital signs before she leaves.
2. Ask the client if she has ever had an allergy to penicillin before.
3. Inform the client that she will need to wait 30 minutes before leaving the clinic.
4. Inform the client that she must have someone drive her home.
5. Advise the client to rest for the remainder of the day.
Correct Answer: 2,3
Rationale 1: There is no reason to have the client lie down. It is not important to assess vital signs unless a problem has developed.
Rationale 2: It is always important to ask about allergies. The nurse must be aware, however, that no history of allergy does not guarantee there will not be an allergic response with this administration.
Rationale 3: It is important that the client be reassessed for development of allergic reaction before leaving the clinic.
Rationale 4: There is no indication that the client will require someone else to drive her home.
Rationale 5: There is no specific reason the client should rest related to administration of penicillin.
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