Two hours after taking a dose of penicillin, a patient arrives in the emergency department complaining of tightness in the throat, pruritus, and red wheals
During the physical assessment, the patient develops difficulty breathing, respirations 36/min, blood pressure 90/42, pulse rate of 120/min. The priority nursing action would be to
a. administer diphenhydramine (Benadryl), because the patient is experiencing a moderate allergic reaction that should improve shortly.
b. sit the patient up in bed, administer oxygen until the symptoms subside, and notify the prescriber.
c. question the patient about any previous allergy to penicillin and report the symptoms to the prescriber.
d. call for assistance, apply oxygen, administer epinephrine as ordered, and notify the prescriber.
ANS: D
The patient is experiencing anaphylaxis, and emergency care must be provided.
Diphenhydramine is most effective when used to manage an allergic reaction that does not include anaphylaxis. This is a life-threatening situation, and emergency care must be provided.
Positional changes and oxygen are not the priority care needed in this situation.
Questioning the patient at this time is inappropriate and disregards the emergency nature of the situation.
You might also like to view...
A nurse educator is teaching a group of nursing students about the function of the state board of nursing. Which information will the educator include in the teaching session? Select all that apply
A) Creating the NCLEX-RN examination B) Defining professional standards C) Investigating violations of the nurse practice act D) Suspending or revoking licenses E) Finding drug treatment centers for impaired nurses
A director of nursing works in a hospital that serves many Jehovah's Witness patients. What action by the nurse would best facilitate culturally appropriate health care?
a. Establish a bloodless surgery program. b. Create an immunization clinic for children. c. Employ spiritual leaders from this faith. d. Allow faith healing ceremonies.
The International Council of Nurses (ICN) Code of Ethics for nurses is primarily a statement in support of:
a. Environmental protection. b. Professional membership. c. Everyday decision making. d. Collective bargaining.
The nurse is teaching about designer drugs. Which definition would the nurse include in the teaching plan?
1. A designer drug is created in an illegal laboratory solely for illegal drug trafficking. 2. A designer drug is made from a naturally occurring substance. 3. Alcohol is a designer drug. 4. A designer drug is less addictive than prescription medications.