A nurse is caring for a client.
Vital Signs.
1600: Nurses’ Notes.
Temperature 37.6°C (99.7°F). Blood pressure 110/58 mm Hg. Heart rate 72/min.
Respiratory rate 18/min.
Pulse oximetry 98% on room air.
1630: Temperature 37.5°C (99.5°F). Blood pressure 78/52 mm Hg. Heart rate 112/min.
Respiratory rate 26/min.
Pulse oximetry 92% on room air.
1600: Antibiotic administered as prescribed.
Bilateral breath sounds clear and present throughout.
1630: Client reports itching on the chest and has urticaria over the chest and trunk.
Client states they are having difficulty swallowing and feel as if there is a lump in their throat.
Bilateral breath sounds with scattered wheezing heard throughout.
Vital Signs.
Nurses’ Notes.
Medication Administration Record.
Cefaclor 500 mg PO q8h.
Select the 3 findings that require immediate follow-up.
A.
Breath sounds at 1600.
B.
Temperature.
C.
Urticaria.
D.
Blood pressure at 1630.
E.
Report of dysphagia.
The Correct answer and Explanation is:
The three findings that require immediate follow-up are:
D. Blood pressure at 1630 C. Urticaria E. Report of dysphagia
Explanation:
1. Blood Pressure at 1630: The blood pressure reading of 78/52 mm Hg at 1630 indicates hypotension. This significant drop from 110/58 mm Hg at 1600 can suggest a severe reaction or other complications. Hypotension may be due to an allergic reaction or an adverse response to the medication, particularly after the administration of Cefaclor, which can cause anaphylactic reactions in susceptible individuals. Immediate follow-up is essential to determine the cause and address potential life-threatening issues like shock or severe allergic reactions.
2. Urticaria: Urticaria (hives) developing over the chest and trunk is a classic sign of an allergic reaction. Given that this occurred after the administration of Cefaclor, it suggests a possible hypersensitivity reaction. Urticaria can be an early indicator of a more severe allergic reaction, such as anaphylaxis. Immediate evaluation is needed to manage the allergic response and prevent progression to more severe symptoms.
3. Report of Dysphagia: Dysphagia (difficulty swallowing) and the sensation of a lump in the throat are concerning symptoms that can indicate angioedema, a severe allergic reaction that may involve swelling of the throat or airway. This condition can compromise the airway and pose a serious risk of airway obstruction. Immediate assessment is required to ensure the client’s airway is secure and to provide appropriate intervention.
Summary:
The blood pressure drop, urticaria, and dysphagia are significant findings that indicate the potential for a severe allergic reaction or other serious complications. These symptoms, particularly when combined with the recent administration of Cefaclor, necessitate urgent assessment and intervention to ensure patient safety and prevent progression to more critical conditions.