Assess the client's respiratory status and oxygen saturation. This is the correct answer because the nurse should follow the ABC (airway, breathing, circulation) priority-setting framework when caring for a client who has an allergic reaction. The nurse should first assess the client's respiratory status and oxygen saturation to determine if they are in respiratory distress or have signs of anaphylaxis, which is a life-threatening emergency. The other actions are also important, but they are not the first priority.

A) Administer an antihistamine as prescribed. This is an incorrect answer because although administering an antihistamine can help reduce the symptoms of an allergic reaction, it is not the first action that the nurse should take. The nurse should first assess the client's respiratory status and oxygen saturation to determine if they are in respiratory distress or have signs of anaphylaxis.

B) Stop the medication infusion and disconnect the IV tubing. This is an incorrect answer because although stopping the medication infusion and disconnecting the IV tubing can prevent further exposure to the allergen, it is not the first action that the nurse should take. The nurse should first assess the client's respiratory status and oxygen saturation to determine if they are in respiratory distress or have signs of anaphylaxis.

D) Notify the provider and document the incident. This is an incorrect answer because although notifying the provider and documenting the incident are important steps in managing an allergic reaction, they are not the first actions that the nurse should take. The nurse should first assess the client's respiratory status and oxygen saturation to determine if they are in respiratory distress or have signs of anaphylaxis.

Answer: C. Cefazolin is a similar type of antibiotic to penicillin, but it has a lower risk of causing an allergic reaction than penicillin. This is the correct answer because cefazolin belongs to the same class of antibiotics as penicillin, which are called beta-lactams. However, cefazolin is a first-generation cephalosporin, which has less cross-reactivity with penicillin than other cephalosporins. This means that clients who are allergic to penicillin have a lower chance of having an allergic reaction to cefazolin than to other beta-lactam antibiotics. The nurse should explain this to the client and monitor them for any signs of an allergic reaction.

A) "Cefazolin is a different type of antibiotic than penicillin, so you will not have an allergic reaction to it." This is an incorrect answer because cefazolin is not a different type of antibiotic than penicillin; they both belong to

the beta-lactam class of antibiotics. Therefore, there is still a possibility that the client could have an allergic reaction to cefazolin if they are allergic to penicillin.

B) "Cefazolin is a synthetic version of penicillin, so it does not contain any of the allergens that cause your reaction." This is an incorrect answer because cefazolin is not a synthetic version of penicillin; they are both derived from natural sources. Therefore, cefazolin could still contain some of the allergens that cause the client's reaction to penicillin.

D) "Cefazolin is a newer type of antibiotic than penicillin, so it has fewer side effects and less potential for causing an allergic reaction." This is an incorrect answer because cefazolin is not a newer type of antibiotic than penicillin; they were both discovered in the 1940s. Therefore, the age of the antibiotic does not determine its side effects or potential for causing an allergic reaction.

Answer: A. Inject the epinephrine into your thigh muscle and hold it for 10 seconds. This is the correct answer because the thigh muscle is the preferred site for administering epinephrine in case of anaphylaxis. The thigh muscle has a large blood supply and can absorb the medication quickly. The nurse should instruct the client to inject the epinephrine into the middle of the outer thigh, at a 90-degree angle, and hold it for 10 seconds to ensure that the full dose is delivered.

B) Inject the epinephrine into your upper arm muscle and hold it for 5 seconds. This is an incorrect answer because the upper arm muscle is not a recommended site for administering epinephrine in case of anaphylaxis. The upper arm muscle has a smaller blood supply and may not absorb the medication as quickly as the thigh muscle. The nurse should instruct the client to inject the epinephrine into the thigh muscle instead.

C) Inject the epinephrine into your abdomen and hold it for 15 seconds. This is an incorrect answer because the abdomen is not a recommended site for administering epinephrine in case of anaphylaxis. The abdomen has more fat tissue and may not absorb the medication as quickly as the thigh muscle. The nurse should instruct the client to inject the epinephrine into the thigh muscle instead.

D) Inject the epinephrine into your buttock and hold it for 20 seconds. This is an incorrect answer because the buttock is not a recommended site for administering epinephrine in case of anaphylaxis. The buttock has more fat tissue and may not absorb the medication as quickly as the thigh muscle. The nurse should instruct

the client to inject the epinephrine into the thigh muscle instead.

Explanation: When a client experiences an allergic reaction, monitoring vital signs is a priority nursing intervention. An allergic reaction can lead to systemic manifestations, such as respiratory distress, hypotension, or tachycardia. Monitoring vital signs allows the nurse to assess the client's overall condition, identify any worsening symptoms, and provide prompt intervention.

A) Administering an antihistamine

While antihistamines may be a part of the treatment plan for allergic reactions, they should not be the nurse's initial priority. The nurse should first assess the client's vital signs and overall stability before administering any medication.

B) Notifying the healthcare provider

While it is important to communicate with the healthcare provider, especially in severe cases, immediate intervention to monitor vital signs and ensure client stability should take precedence before notifying the healthcare provider.

D) Applying a cool compress to the affected area

Applying a cool compress may provide local relief for symptoms such as itching or redness. However, in the case of an allergic reaction, systemic manifestations require immediate attention. Therefore, monitoring vital signs takes priority over local comfort measures.

Explanation: When a client is experiencing an anaphylactic reaction, ensuring airway patency is the nurse's first priority. Airway obstruction due to swelling or bronchospasm can rapidly lead to respiratory distress and hypoxia. Assessing airway patency allows the nurse to determine the severity of the situation and initiate appropriate interventions.

A) Administering epinephrine

Epinephrine is a critical medication for treating anaphylaxis, but the nurse must first ensure airway patency before administering any medication. The administration of epinephrine would follow the assessment and confirmation of airway patency.

B) Calling for emergency assistance

While calling for emergency assistance is essential in managing anaphylactic reactions, it should not take precedence over assessing airway patency. The nurse must first assess the client's immediate condition and initiate interventions to secure the airway.

D) Positioning the client in a supine position

Positioning the client in a supine position may be appropriate in some situations, but it is not the first priority when managing an anaphylactic reaction. Airway assessment and intervention should be the initial focus to address potential airway obstruction.

A nurse is providing education to a client about self-management of allergic reactions.

Explanation: Carrying an epinephrine auto-injector is a crucial self-management strategy for individuals with known allergies. In case of an allergic reaction, epinephrine can be administered promptly to counteract severe symptoms and potentially prevent anaphylaxis. This response demonstrates the client's understanding of the importance of being prepared to manage allergic reactions.

A) "I will avoid all potential allergens to prevent any reaction."

While avoiding known allergens is an essential aspect of managing allergies, it is often challenging to avoid all potential allergens. Some allergens may be difficult to identify or encounter unexpectedly. Carrying an epinephrine auto-injector provides a more comprehensive approach to self-management.

C) "I will take antihistamine medication every day to prevent reactions."

Antihistamines are primarily used for relieving symptoms of allergic reactions, such as itching or congestion, rather than preventing reactions. Taking antihistamines every day is not the recommended approach for preventing allergic reactions.

D) "I will self-administer corticosteroid injections during allergic reactions."

Corticosteroid injections are generally administered by healthcare professionals and are not intended for self-administration during allergic reactions. Corticosteroids may be part of the treatment plan for severe allergic reactions but are typically prescribed and administered under medical supervision.