The nurse initiates an infusion of piperacillin-tazobactam for a client with a urinary tract infection. Five minutes into the infusion, the client reports not feeling well. Which client manifestation should the nurse identify as a reason to stop the infusion?
A.
Scratchy throat.
B.
Pupillary constriction.
C.
Hypertension.
D.
Bradycardia.
The Correct Answer and Explanation is:
The correct answer is A. Scratchy throat.
When a client reports not feeling well during an infusion, it is essential for the nurse to identify signs that could indicate a serious adverse reaction or an allergic response. Among the options provided:
- A. Scratchy throat: This manifestation is a potential sign of an allergic reaction or an anaphylactic response. Allergic reactions to medications, including piperacillin-tazobactam, can cause symptoms such as a scratchy or sore throat, itching, rash, or swelling. Anaphylaxis, a severe allergic reaction, often starts with symptoms like a scratchy throat or hoarseness and can rapidly progress to more severe symptoms, including difficulty breathing, swelling of the face or throat, and a drop in blood pressure. Immediate cessation of the infusion and further assessment are crucial to prevent worsening of the reaction.
- B. Pupillary constriction: This is not typically associated with an allergic reaction to medications. Pupillary changes are more often related to neurological or systemic conditions rather than acute drug reactions.
- C. Hypertension: While hypertension can be a side effect of some medications, it is not usually an immediate concern with piperacillin-tazobactam infusion. The nurse should monitor blood pressure, but hypertension alone, especially in the early minutes of the infusion, is less likely to necessitate stopping the infusion compared to other more urgent symptoms.
- D. Bradycardia: Bradycardia (slow heart rate) is not a common immediate reaction to piperacillin-tazobactam. It may be a concern in the context of severe allergic reactions or other conditions, but it is not as urgent a sign for stopping the infusion as symptoms indicating a severe allergic reaction.
In summary, a scratchy throat in this context is the most concerning symptom and suggests a possible allergic reaction or anaphylaxis. Immediate action to stop the infusion, assess the client’s condition, and initiate appropriate interventions (such as administering antihistamines or epinephrine, if needed) is necessary to ensure client safety.