The nurse administers the client's medication and, within 30 minutes, the client has bilateral wheezing, large red blotches on the face, and is anxious and dizzy. Which should the nurse im-plement?

Question

1. Encourage the client to drink plenty of fluids.
2. Direct a colleague to contact the provider stat.
3. Check the MAR for an antihistamine as needed.
4. Document potential client allergy to medication.

Answer 1

2
2. The client has clinical indicators of a moderate to severe hypersensitivity reaction, most likely related to the medication. The wheezing increases the risk of impairing the client's airway and the blood pressure can be low already, as evidenced by client dizziness. The nurse should stay with the client and wait for emergency equipment, supplies, and personnel to assist. In the meantime, the nurse should plan to support the client's airway, breathing, and circulation.
1. Hydrating the client will not flush the allergic reaction from the client because it is under way; besides, drinking fluid increases the risk of aspiration of gastric contents or choking.
3. An antihistamine potentially helps to reverse some of the allergic effects; however, the nurse should not leave the client.
4. The nurse documents the events after the client is stable. The nurse needs to help the client and family understand the nature of the reaction, to put the information in the client's medical record, and to share the information with other providers.