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Difficulty: MediumPharmacological Therapies

Fifteen minutes after receiving an intramuscular injection of ceftriaxone for a respiratory infection, a client suddenly reports feeling dizzy and extremely restless. The practical nurse assesses the client and notes a heart rate of 122122 beats per minute and a blood pressure of 84/50 mmHg84/50\text{ mmHg}. Which action should the nurse take first?

  1. Activate the rapid response team and remain with the client to monitor their airway and breathing.Answer
  2. B
    Offer the client a prescribed as-needed analgesic, assuming the restlessness is caused by injection site pain.
  3. C
    Document the vital signs as a transient reaction to the medication and reassess the client in 3030 minutes.
  4. D
    Independently initiate a rapid intravenous fluid bolus to treat the client's hypotension.

Answer

The correct action is to activate the rapid response team and remain with the client to monitor their airway and breathing.
The client's sudden onset of restlessness, dizziness, tachycardia, and hypotension shortly after receiving an antibiotic injection are classic signs of anaphylactic shock. Anaphylaxis is a life-threatening allergic reaction. According to the ABC (Airway, Breathing, Circulation) framework, the nurse must prioritize airway and circulation. The immediate and most appropriate action is to activate the rapid response team or emergency medical services while staying with the client to maintain the airway and provide support until advanced help arrives.

Step-by-Step Solution

1
Analyze the client's presentation and vital signs following the medication administration.
The client has developed tachycardia (122122 beats per minute), hypotension (84/50 mmHg84/50\text{ mmHg}), dizziness, and restlessness.
Identifying abnormal clinical data is the foundational step in recognizing an adverse pharmacological reaction.
2
Correlate the clinical findings with potential complications of the administered antibiotic.
The acute onset of these symptoms indicates anaphylactic shock, a severe and life-threatening allergic reaction to the ceftriaxone.
Antibiotics are a common cause of anaphylaxis, which rapidly compromises circulation and the airway.
3
Determine the priority nursing intervention based on the practical nurse scope of practice and the ABC framework.
The nurse must immediately call for emergency assistance while staying with the client to maintain airway patency.
In emergent situations, securing advanced medical help while providing basic life support is the highest priority.

Key Concept

Recognizing and responding to severe adverse medication reactions using the Airway, Breathing, Circulation (ABC) prioritization framework.
Estimated Time:1m 30s
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Topics

Pharmacological Therapies

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