A patient develops wheezing, facial swelling, and widespread hives shortly after an intravenous antibiotic begins. What should the nurse do first?
Correct answer: A. Stop the antibiotic infusion and call for emergency help
- A. Stop the antibiotic infusion and call for emergency help
- B. Slow the infusion and reassess the skin in 10 minutes
- C. Document the reaction and ask the prescriber to review it
- D. Offer oral fluids and place the patient in a sitting position
Explanation
Stopping the suspected antibiotic removes the trigger while emergency help is summoned. Wheezing and facial swelling suggest anaphylaxis, so airway and circulation may deteriorate rapidly. Slowing the infusion or documenting first delays treatment.
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About Clinical Judgement and Prioritisation
Clinical judgement links assessment findings, nursing knowledge and patient responses to a safe decision. Coverage includes ABCDE assessment, recognising actual or potential instability, prioritising airway, breathing and circulation, using urgency and risk rather than routine order, reassessing after intervention, and distinguishing a nursing priority from a medical diagnosis or a task that can wait.
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