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NurseDive Free Nursing Practice Question
A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is initiated. In which, order should the nurse implement these interventions? (Arrange the actions in order of priority, with the highest priority first, and the least priority last or at the bottom.)
A. Stop the Infusion.
B. Assess vital signs
C. Contact the healthcare provider.
D. Initiate an adverse event report.
E. Document reaction to the drug.
This question is an excerpt from Nurse Dive's nursing test bank - RN Hesi Exit Proctored Exam. Take the full exam now
Full Explanation
A) This is because the client is experiencing an allergic reaction to piperacillin, which can be life-threatening. The nurse should stop the infusion immediately to prevent further exposure to the drug and assess vital signs to monitor for signs of anaphylaxis, such as hypotension, tachycardia, wheezes, or stridor.
B) Assessing vital signs is a priority to determine the severity of the reaction and the client's overall condition.
C) The nurse should contact the healthcare provider to report the situation and obtain orders for treatment, such as antihistamines, corticosteroids, or epinephrine.
D) The nurse should initiate an adverse event report to document the incident and follow the facility's protocol for reporting medication errors.
E) The nurse should also document the reaction to the drug in the client's chart and notify the pharmacy to avoid future administration of piperacillin or related antibiotics.
Similar Questions
Exhibits
For each client statement, click to highlight the statement(s) below that require follow up teaching by the nurse.
"I am at high risk for post-traumatic-stress disorder because I have acute stress"
"I can use holistic approaches like meditation to help my symptoms."
"I can learn to manage my thoughts better through therapy."
"Many people have the same response to a stressful situation as I am having"
"This diagnosis means that I am crazy."
"I will probably need to be on medication for the rest of my life."
A. I am at high risk for post-traumatic-stress disorder because I have acute stress
None
B. I can use holistic approaches like meditation to help my symptoms
None
C. I can learn to manage my thoughts better through therapy
None
D. Many people have the same response to a stressful situation as I am having
None
E. This diagnosis means that I am crazy
None
F. I will probably need to be on medication for the rest of my life
None
Full Explanation
Correct- This statement indicates a misunderstanding about the relationship between acute stress disorder (ASD) and post-traumatic stress disorder (PTSD). While both are related to traumatic events, ASD is considered an initial reaction that typically resolves within three days to four weeks, whereas PTSD involves symptoms persisting for more than a month. The nurse should provide education on the different timelines and criteria for these disorders.
Incorrect- This statement reflects a proactive approach to managing symptoms and stress through holistic methods like meditation. There's no need for follow-up teaching here.
Incorrect- This statement shows the client's recognition of the potential benefits of therapy in managing their thoughts and emotions. It indicates their willingness to engage in effective coping strategies.
Incorrect- This statement reflects an understanding that their response to the traumatic event is not uncommon and that others may have similar reactions. It's a valid perspective on shared experiences during challenging times.
Correct- The statement "This diagnosis means that I am crazy" reflects a common misconception about mental health diagnoses. The term "crazy" is stigmatizing and does not accurately represent the nature of mental health conditions. The nurse should offer reassurance that a diagnosis of ASD does not define a person's overall mental state and emphasize the importance of seeking help without judgment.
Correct- The statement "I will probably need to be on medication for the rest of my life" implies a sense of hopelessness or a narrow perspective about treatment options. While medication might be part of the treatment plan for some individuals, it's important to emphasize that treatment is personalized and can include a combination of therapies, coping strategies, and lifestyle adjustments. The nurse should encourage an open discussion about treatment goals and possibilities.
A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is initiated. In which, order should the nurse implement these interventions? (Arrange the actions in order of priority, with the highest priority first, and least priority last or at the bottom.)
A. Stop the Infusion.
B. Assess vital signs.
C. Contact the healthcare provider.
D. Initiate an adverse event report.
E. Document reaction to the drug.
Full Explanation
A) This is because the client is experiencing an allergic reaction to piperacillin, which can be life-threatening. The nurse should stop the infusion immediately to prevent further exposure to
the drug and assess vital signs to monitor for signs of anaphylaxis, such as hypotension, tachycardia, wheezes, or stridor.
B) Assessing vital signs is a priority to determine the severity of the reaction and the client's overall condition.
C) The nurse should contact the healthcare provider to report the situation and obtain orders for treatment, such as antihistamines, corticosteroids, or epinephrine.
D) The nurse should initiate an adverse event report to document the incident and follow the facility's protocol for reporting medication errors.
E) The nurse should also document the reaction to the drug in the client's chart and notify the pharmacy to avoid future administration of piperacillin or related antibiotics.
The client reports having a cold earlier in the week, but she was feeling better before the hike. The nurse begins client education and asks the client what potential asthma triggers may have been involved in her recent exacerbation. For each statement click to specify if the client has an understanding or no understanding of asthma triggers.
Client Statements below.
A. I should have taken some allergy medications before going on the hike.
B. I should have eaten a snack halfway through the hike.
C. My friend smoked cigarettes during the hike.
D. I have been very stressed out lately and should work on stress management.
E. I should have taken an extra dose of Fluticasone- Salmeterol.
Full Explanation
A. Understanding: The client recognizes that taking allergy medications before the hike might have helped prevent an exacerbation.
B. No understanding: The client doesn't realize that eating a snack could impact asthma symptoms. Proper education is needed here.
C. Understanding: The client acknowledges that exposure to cigarette smoke during the hike could have contributed to the exacerbation.
D. Understanding: The client identifies that stress management could be important in preventing asthma exacerbations.
E. No understanding: The client is not aware that taking an extra dose of Fluticasone-Salmeterol could have been beneficial. Further education is necessary.