For each medication reaction, indicate whether it suggests an allergy and whether it requires immediate emergency action. Select all that apply in each row.
Matrix
Choose your responses, then check the answer.
Explanation
Generalized hives with wheezing and tongue swelling with hypotension are allergic patterns with respiratory or cardiovascular danger signs and require immediate emergency action. A localized pruritic rash can suggest a drug allergy but, without airway, breathing, or circulation compromise, does not by itself establish current anaphylaxis. Mild nausea, isolated diarrhea, and family history without a client reaction do not independently establish allergy or an emergency. Suspected anaphylaxis is treated promptly with intramuscular epinephrine under the emergency protocol.
Correct Answer Mark both columns for generalized hives with wheezing and for tongue swelling with hypotension. Mark allergy only for the localized pruritic rash. Mark neither column for isolated nausea, isolated diarrhea, or family history without a client reaction.
Why It Fits Wheezing, tongue swelling, and hypotension are respiratory or cardiovascular danger signs after medication exposure. These findings require rapid anaphylaxis management, including intramuscular epinephrine according to protocol.
Clinical Picture An allergy can be present without current anaphylaxis, as with a non-severe pruritic rash. Gastrointestinal adverse effects may represent intolerance, and a relative's reaction is not the client's documented allergy.
Memory Link Skin plus breathing or circulation equals emergency until proven otherwise.
NCLEX Rule Do not delay emergency treatment while waiting for every possible organ system to become involved. Match the complete cue pattern to current airway, breathing, and circulation risk.
Why the Alternatives Fail Labeling all nausea or diarrhea as allergy creates inaccurate records. Treating family history as the client's reaction is also incorrect. Conversely, classifying wheezing with hives as nonemergent misses a potentially fatal progression.
Source
1CDC: Preventing and Managing Adverse Reactions
22026 NCLEX-RN Test Plan
The nurse is reconciling medication reactions in an acute-care setting. Immediate emergency action means stop the suspected exposure, activate the emergency response, support airway and circulation, and give intramuscular epinephrine according to the emergency protocol when anaphylaxis is suspected.
Medication allergy — An immune-mediated reaction to a medication. Document the client's actual reaction pattern rather than recording an isolated adverse effect or family history as the client's allergy.
Anaphylaxis — A rapidly progressive, potentially fatal systemic hypersensitivity reaction. Respiratory or cardiovascular compromise after a likely exposure requires immediate emergency action and intramuscular epinephrine according to protocol.
Medication intolerance — A nonimmune adverse effect such as isolated nausea or diarrhea. Intolerance should be assessed and documented accurately but is not automatically an allergy or anaphylaxis.