A patient with no known allergies is to receive penicillin every six hours. When administering the medication, the nurse observes a fine rash on the patient's skin. The most appropriate nursing action would be?

1. A

   Administer the medication and notify the physician

2. B

   Withhold the medication and notify the physician

3. C

   Apply corn starch soaks to the rash

4. D

   Administer the medication with an antihistamine

Appeared in: JSSH Staff Nurse - 2019

Explanation

• A fine rash appearing after a decision to administer penicillin is a classic sign of a hypersensitivity (allergic) reaction.
• The primary principle of patient safety is to 'do no harm.' Continuing the medication could lead to a more severe, life-threatening anaphylactic reaction.
• Withholding the medication is the immediate priority to prevent worsening of the reaction.
• Notifying the physician is the essential next step to ensure the patient is properly assessed and an alternative treatment plan is established.

Why Other Options Were Wrong

• Option A: Administering the medication is unsafe as it continues to expose the patient to a potential allergen, risking a more severe reaction.
• Option C: This action only treats a symptom (the rash) and does not address the underlying cause (the allergic reaction). It is a palliative measure, not a primary safety intervention.
• Option D: Administering the medication with an antihistamine is dangerous. While it might mask minor symptoms, it does not stop the underlying allergic cascade and can provide a false sense of security while a severe reaction develops.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Recognition and management of a drug-induced allergic reaction to guide bedside assessment, documentation, and the next nursing action.
• This scenario highlights the nurse's critical role in patient assessment and advocacy. The nurse is often the first person to detect an adverse drug reaction.
• The principle of 'Stop and Notify' is a fundamental safety protocol in medication administration when an adverse reaction is suspected.
• What if the patient had a known history of a mild rash to amoxicillin (a type of penicillin)? In this case, the nurse should have questioned the order for penicillin before even preparing it, due to the high risk of cross-sensitivity, and clarified with the physician.

How to Approach the Question

• First, identify the core clinical problem: a patient is showing a new symptom (rash) at the time of administration of a drug known for causing allergies (penicillin).
• Second, apply the principle of patient safety. The top priority is to prevent harm. Which action best prevents potential harm?
• Third, evaluate the options. Administering the drug (Options A and D) increases risk. Treating only the symptom (Option C) ignores the risk.
• Fourth, conclude that the only option that prioritizes safety is to stop the potential cause (withhold the drug) and escalate to the provider who can make a new plan (notify the physician).

Concept Tested & Keywords

• Concept Tested: Recognition and management of a drug-induced allergic reaction.
• Stem keywords: penicillin, rash, allergies, nursing action
• Lead-in keywords: most appropriate
• Clinical cues: A new fine rash observed during medication administration is a classic sign of a potential drug hypersensitivity reaction.

Question ID

QiO1UGnTvdaGVY22hnAZby

Copy ID

Reference Book

E6 Pharmacology Nursing Lilley 11e Part 2 pp. 310-312, 309-311