The nurse administers a patient's medication; within 30 minutes the patient has bilateral wheezing and large red blotches on the face and is anxious and dizzy. Which should the nurse implement?

Question

a. Encourage the patient to drink plenty of fluids.
b. Direct a colleague to contact the provider stat.
c. Check the medication administration record (MAR) for an antihistamine as needed.
d. Document potential patient allergy to me-dication.

Answer 1

B
The patient has clinical indicators of a moderate-to-severe hypersensitivity reaction, most likely related to the medication. The wheezing increases the risk of impairing the patient's airway, and the blood pressure can be low already, as evidenced by patient dizziness. The nurse should stay with the patient and wait for emergency equipment, supplies, and personnel to assist. In the meantime he or she should plan to support the patient's airway, breathing, and circulation. Hy-drating the patient will not flush the allergic reaction from him or her because it is under way; besides, drinking fluid increases the risk of aspiration of gastric contents or choking. An antihis-tamine potentially helps to reverse some of the allergic effects; however, the nurse should not leave the patient. The nurse documents the events after the patient is stable.