Page 1350 - Saunders Comprehensive Review For NCLEX-RN

f. Anxiety or agitation
g. Flushed appearance
h. Hypotension
i. Decreased sensorium
j. Cyanosis
3. Interventions for an anaphylactic reaction (see Priority
Nursing Actions)

Priority Nursing Actions

Anaphylactic Reaction Occurring from Medication
1. Assess respiratory status.
2. Stop the medication.
3. Contact the primary health care provider (PHCP) and the Rapid Response Team
if necessary.
4. Administer oxygen.
5. Maintain the intravenous (IV) access with normal saline.
6. Raise the client’s feet and legs, if not contraindicated.
7. Administer prescribed emergency medications, such as epinephrine.
8. Monitor vital signs.
9. Document the event, actions taken, and the client’s response.

Reference

Ignatavicius, Workman, Rebar (2018), p. 365.

II. Alkylating Medications (Box 45-1)
A. Description
1. Break the DNA helix, thereby interfering with DNA
replication
2. Cell cycle phase–nonspecific medications
B. Side and adverse effects
1. Anorexia, nausea, and vomiting may occur.
2. Stomatitis may occur.
3. Rash may occur.
4. Client may feel IV site pain during IV administration.
5. Busulfan may cause hyperuricemia.
6. Chlorambucil and mechlorethamine may cause
gonadal suppression and hyperuricemia.
7. Cisplatin, a platinum compound, may cause
ototoxicity, tinnitus, hypokalemia, hypocalcemia,
hypomagnesemia, and nephrotoxicity.
C. Interventions: Refer to Section I, C (Antineoplastic Medications—
General Interventions).
1. Cyclophosphamide may cause alopecia, gonadal
suppression, hemorrhagic cystitis, and hematuria.
2. Ifosfamide may cause hemorrhagic cystitis, and
neurotoxicity.
3. Assess results of pulmonary function tests.
4. Assess results of chest radiography and renal and liver

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