Thirty minutes after receiving meperidine, the client develops a temperature of 101°F and the skin is warm and flushed with a notable rash on the chest and back. The nurse contacts the primary health care provider and begins to document on an incident report. Which information should be included?
The client had an allergic reaction to the ordered meperidine.
The primary health care provider was notified because the client developed a rash after receiving an opioid analgesic.
The client’s skin was warm and flushed, and a rash was noted on the chest and back.
Thirty minutes after receiving meperidine, the temperature was 101°F (38.3°C).
The Correct Answer is D
Choice A rationale
Stating that the client had an allergic reaction to the ordered meperidine is not objective and does not provide specific details about the client’s condition.
Choice B rationale
Notifying the primary health care provider because the client developed a rash after receiving an opioid analgesic is important, but it does not include all the necessary details about the client’s condition.
Choice C rationale
Documenting that the client’s skin was warm and flushed, and a rash was noted on the chest and back is important, but it does not include the timing of the reaction or the client’s temperature.
Choice D rationale
Documenting that thirty minutes after receiving meperidine, the temperature was 101°F (38.3°C), the client’s skin was warm and flushed, and a rash was noted on the chest and back provides a complete and objective account of the client’s condition and the timing of the reaction.
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Correct Answer is D
Explanation
Choice A rationale
Diphenhydramine does not expand blood volume. It is an antihistamine used to prevent allergic reactions.
Choice B rationale
Diphenhydramine does not enhance clotting factors. It is used to manage allergic reactions.
Choice C rationale
While diphenhydramine can help manage fever and chills, its primary purpose before a blood transfusion is to prevent allergic reactions.
Choice D rationale
Administering diphenhydramine before a blood transfusion helps prevent urticaria and other allergic reactions by blocking histamine release. .
Correct Answer is A
Explanation
Choice A rationale
Shutting off the intravenous infusion is the immediate action to take when a client reports difficulty swallowing during infliximab infusion. This could indicate an infusion reaction or anaphylaxis, which requires immediate cessation of the infusion to prevent further complications.
Choice B rationale
Notifying the primary health care provider is important, but the immediate action should be to stop the infusion to prevent further adverse reactions.
Choice C rationale
Having the client take deep breaths and try to relax is not appropriate in this situation, as it does not address the potential infusion reaction or anaphylaxis.
Choice D rationale
Obtaining a prescription for oral diphenhydramine may be part of the treatment for an infusion reaction, but the immediate action should be to stop the infusion. .