Question

a client is prescribed a second dose of iv ceftriaxone postoperatively. the nurse notes urticaria and dyspnea. which of the following actions should the nurse prioritize?

administer oxygen.
administer diphenhydramine.
notify the charge nurse.
discontinue the infusion.

Explanation:

Analyze clinical presentation

Using the Nursing Assessment knowledge point
The client is receiving an intravenous infusion of ceftriaxone (a cephalosporin antibiotic) and exhibits urticaria (hives) and dyspnea (difficulty breathing). These signs indicate a severe systemic allergic reaction (anaphylaxis).

Determine priority intervention

Using the Medication Error Intervention knowledge point
When a client experiences a life-threatening hypersensitivity reaction during an active intravenous infusion, the immediate priority is to stop the exposure to the offending agent to prevent further clinical deterioration.

Evaluate alternative choices

While administering oxygen, giving diphenhydramine, and notifying the charge nurse are appropriate subsequent steps in managing anaphylaxis, none of these actions should precede stopping the infusion of the allergen.

Answer:

• Administer oxygen.
• Administer diphenhydramine.
• Notify the charge nurse.
• Discontinue the infusion. (Correct answer)