A client with primary syphilis was treated with an intramuscular injection of benzathine penicillin G. Later, the client reports a hard painful lump at the injection site and aching joints. Which is the nurse's highest priority initial action?
a. Assess the client's vital signs.
b. Give the client acetaminophen (Tylenol).
c. Document the finding in the chart.
d. Apply a warm compress to the site.
A
A common reaction to penicillin injections for primary syphilis is the Jarisch-Herxheimer reaction, caused by rapid destruction of the causative microorganism and release of intracellular products. This is not usually serious, but it can cause fever and hypotension. The nurse should first assess the client's blood pressure for stability and should take the temperature. Then if the client's condition warrants, the nurse can administer acetaminophen or even fluids if needed. Documentation can be completed after the assessment is done. A warm compress to the site may or may not be helpful.
You might also like to view...
The nurse is providing care for an older patient who is taking digoxin. The nurse should keep in mind all of the following about digoxin except
a. It is used in the treatment of congestive heart failure to strengthen the force of the heart contraction b. High doses may cause confusion as a side effect c. It requires periodic monitoring of drug blood levels to prevent toxicity d. Falling from orthopnea is a common and frequent side effect
A client with borderline personality disorder has lacerated her wrists. The physician orders daily
dressing changes for the lacerations. The nurse performing this care should a. encourage the client to express anger. b. provide care in a matter-of-fact manner. c. be kindly, sympathetic, and concerned. d. offer to listen to the client's feelings about cutting.
When a health care provider is prescribing a medication for tinea, which of the following should the nurse include in the education regarding use of the medication?
A) Topical medication can be absorbed through the skin, so watch for any side effects. B) Use of topical medication is safe and does not require any special education. C) Topical medications can be shared if other family members develop the same symptoms. D) Use of a topical medication is the best way to treat any problem in a child.
Which of the following is a purpose of the health care delivery system in a community?
A. Disease prevention and treatment
B. Public education
C. Health care research
D.
| All of these |