A nurse is caring for a client who just received a dose of IV ampicillin. Which of the following client reactions requires priority intervention by the nurse?
A.
BP 98/62
B.
Urticaria
C.
Wheezing
D.
Pulse rate 104/min
The Correct answer and Explanation is:
The correct answer is C. Wheezing.
Explanation:
Wheezing is a high-pitched, whistling sound that occurs when air flows through narrowed airways, often indicating bronchoconstriction or airway obstruction. When a client begins wheezing after receiving intravenous (IV) ampicillin, it is a sign of a potential severe allergic reaction, known as anaphylaxis. Anaphylaxis is a medical emergency that can be life-threatening if not promptly addressed. It typically involves multiple body systems, with respiratory compromise being one of the most serious manifestations.
Priority in Nursing:
In any scenario involving anaphylaxis, airway, breathing, and circulation (ABC) take precedence. Wheezing suggests that the client’s airway is compromised due to the body’s immune response to the ampicillin. If left untreated, the wheezing could escalate to complete airway obstruction, leading to respiratory failure, hypoxia, and potentially death. Therefore, immediate intervention is crucial to maintain a patent airway and provide oxygenation.
The nurse should stop the ampicillin infusion immediately, administer oxygen, and prepare to administer epinephrine, the first-line treatment for anaphylaxis. Additionally, other interventions might include antihistamines (e.g., diphenhydramine), corticosteroids, and bronchodilators to manage inflammation and airway constriction.
Other Options:
- A. BP 98/62: While this blood pressure reading is slightly low, it is not immediately life-threatening. Hypotension can occur during anaphylaxis, but the respiratory distress indicated by wheezing takes priority.
- B. Urticaria: Urticaria (hives) is a common sign of an allergic reaction, but it is not as life-threatening as respiratory symptoms like wheezing. Hives can be managed with antihistamines and are not considered a medical emergency unless accompanied by systemic symptoms like wheezing, angioedema, or hypotension.
- D. Pulse rate 104/min: Tachycardia can occur during an allergic reaction or anxiety, but like the blood pressure reading, it is not immediately life-threatening compared to airway compromise.
In summary, the nurse’s primary focus should be on the client’s wheezing, as it indicates airway involvement, making it the highest priority for immediate intervention.