Question

A client receives meperidine (Demerol) by the intramuscular (IM) route. Thirty minutes after receiving the medication, the client develops signs of an allergy to the medication. The client's temperature is 101° F, and the skin is warm and flushed with a notable rash on the chest and back. The nurse further assesses the client, contacts the health care provider, and begins to document on an incident report. Which information should the nurse accurately document?

A. The client had an allergic reaction to the meperidine.
B. The health care provider was notified because the client developed a rash after receiving meperidine.
C. The client apparently is allergic to meperidine as noted by a temperature of 101° F, warm and flushed skin, and a rash on the chest and back.
D. Thirty minutes after receiving meperidine, the temperature was 101° F., the client's skin was warm and flushed, and a rash was noted on the chest and back; the health care provider was notified.

Answer 1

The nurse should document objective observations and actions taken without making assumptions about the allergic reaction to meperidine.

Step-by-step explanation:

When documenting an incident like an allergic reaction in a medical setting, it's important to include factual, specific, and objective information without making assumptions. The correct documentation should include observation of symptoms, the time they occurred, and the actions taken. Therefore, the nurse should document that "Thirty minutes after receiving meperidine, the temperature was 101° F., the client's skin was warm and flushed, and a rash was noted on the chest and back; the health care provider was notified." This statement is factual and does not assume the client is allergic, as diagnosis should be left to the healthcare provider.