# A 50-year-old client on day 8 of TMP-SMX develops fever, malaise, and a painful spreading rash with target lesions, mucosal blisters in the mouth and conjunctivae, and skin sloughing on light pressure. Which is the priority nursing action?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375240&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PA

## Question

A 50-year-old client on day 8 of TMP-SMX develops fever, malaise, and a painful spreading rash with target lesions, mucosal blisters in the mouth and conjunctivae, and skin sloughing on light pressure. Which is the priority nursing action?

## Option

1. Stop TMP-SMX immediately, contact prescriber, prepare emergency transfer to burn or ICU; this is Stevens-Johnson Syndrome or TEN — protect skin and airway, replace fluids/electrolytes, analgesia, ophthalmology/dermatology consults, mark a permanent sulfa allergy and avoid all sulfa drugs lifelong. **✔ Correct answer**
2. Administer oral diphenhydramine 50 mg and apply triamcinolone 0.1% cream to affected areas, observe for 4 hours, and if no progression, discharge with a prescription for antihistamines and a follow-up appointment in 2 days, advising to continue the TMP-SMX course.
3. Reassure the client that these symptoms are a transient sulfonamide reaction, administer the next scheduled dose of TMP-SMX, apply calamine lotion to the rash, document the findings, monitor temperature every 4 hours, and plan to notify the prescriber if skin sloughing increases.
4. Apply mupirocin ointment to skin lesions to prevent secondary bacterial infection, continue the TMP-SMX as prescribed, schedule a dermatology consultation for next week, instruct the client to use a soft-bristled toothbrush for oral lesions, and advise taking acetaminophen for fever if needed.

**Correct answer: 1**

## Explanation

Stevens-Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe cutaneous adverse reactions on a continuum (SJS less than 10 percent, SJS/TEN overlap 10-30 percent, TEN over 30 percent body surface area sloughing). Common triggers: sulfonamides, allopurinol, anticonvulsants (carbamazepine, lamotrigine, phenytoin), nevirapine, NSAIDs, and others. Onset typically days to weeks after starting the drug. Presentation: prodromal fever, malaise, sore throat, conjunctivitis; then painful erythematous to dusky macules with target lesions, blistering, positive Nikolsky sign (skin slides off with light pressure), mucosal involvement of mouth, eyes, genitals. Mortality is high — TEN up to 30 percent. Standard nursing response: (1) immediately stop the offending drug and any cross-reactive drugs; (2) emergency transfer to a burn or ICU unit because the loss of skin barrier resembles severe burns; (3) airway protection, fluid and electrolyte management, nutrition, infection prevention, pain control, eye care to prevent corneal scarring; (4) consults with dermatology, ophthalmology, possibly intensive care and burn surgery; (5) document the drug as a permanent allergy in the chart and educate the patient and family to avoid sulfa-containing drugs forever; medical alert bracelet recommended. Continuing the drug, redosing, antihistamine alone, or topical ointment alone are unsafe and life-threatening.

## In-depth explanation

SJS/TEN is a dermatologic emergency. Stop drug, transfer to burn/ICU, protect skin and airway, lifelong allergy label.

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