Question

A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin that is initiated. In what order should the nurse implement these interventions? (arrange the actions in order of priority, with highest priority first, and least priority last or at the bottom.)

1. Document reaction to the drug
2. Initiate an adverse event report
3. Contact the health care provider
4. Assess vital signs
5. Stop the infusion

Answer 1

Option D. The nurse should prioritize assessing vital signs, stopping the infusion, and contacting the health care provider when a client develops urticaria after a secondary infusion of piperacillin.

Step-by-step explanation:

The nurse should implement the interventions in the following order of priority:

1. Assess vital signs: This is the highest priority as it helps the nurse determine the client's current condition and monitor for any signs of worsening allergic reaction.
2. Stop the infusion: Stopping the infusion of piperacillin is important to prevent further exposure to the allergen and minimize the client's symptoms.
3. Contact the health care provider: Contacting the health care provider is necessary to inform them about the client's allergic reaction and seek further guidance on appropriate treatment.
4. Document reaction to the drug: Documenting the client's reaction is important for accurate record-keeping and future reference.
5. Initiate an adverse event report: Initiating an adverse event report helps ensure that the appropriate authorities are notified of the client's reaction and can take appropriate actions.