Difficulty: Medium
Average Score: 63%
Simulated
A nurse is caring for a client who has streptococcal pneumonia and a prescription for penicillin Gby intermittent IV bolus. 10 minutes into the infusion of the third dose, the client reports that the IV site itches and that he feels dizzy and short of breath. Which of the following actions should the nurse take first?
Correct answer
B
Rationale
The correct answer is B: Stop the infusion. The client is showing signs of a potential allergic reaction to penicillin, which can be life-threatening. Stopping the infusion is the priority to prevent further administration of the allergen. This action takes precedence over calling the provider, as immediate intervention is required. Auscultating breath sounds can be done after stopping the infusion to assess for respiratory distress. Elevating the head of the bed may be needed if the client develops respiratory distress but is not the first action to take in this situation.