The nurse is administering the first dose of ampicillin intramuscularly to a client with a severe infection. In addition to the six rights of medication administration, an important priority nursing action is to:
1. monitor bowel sounds.
2. teach the client about the side effects of the drug.
3. encourage the client to increase fluid intake.
4. monitor the client closely for hypersensitivity with the first dose.
Correct Answer: 4
Rationale 1: The chance of hypersensitivity is greater with parenteral administration of ampicillin; so while monitoring bowel sounds is important, it is not as important as another nursing action.
Rationale 2: The chance of hypersensitivity is greater with parenteral administration of ampicillin; so while teaching about side effects is important, it is not as important as another nursing action.
Rationale 3: The chance of hypersensitivity is greater with parenteral administration of ampicillin; so while encouraging fluid intake is important, it is not as important as another nursing action.
Rationale 4: The chance of hypersensitivity is greater with parenteral administration of ampicillin. The priority nursing action is to monitor the client for 30 minutes following administration.
Global Rationale: Hypersensitivity may occur even with the first dose of a medication. The nurse must monitor for that possibility.
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