The nurse is administering the first dose of ampicillin intramuscularly to a client with a severe ...

Correct Answer: 4
Rationale 1: The chance of hypersensitivity is greater with parenteral administration of ampicillin; so while monitoring bowel sounds is important, it is not as important as another nursing action.
Rationale 2: The chance of hypersensitivity is greater with parenteral administration of ampicillin; so while teaching about side effects is important, it is not as important as another nursing action.
Rationale 3: The chance of hypersensitivity is greater with parenteral administration of ampicillin; so while encouraging fluid intake is important, it is not as important as another nursing action.
Rationale 4: The chance of hypersensitivity is greater with parenteral administration of ampicillin. The priority nursing action is to monitor the client for 30 minutes following administration.
Global Rationale: Hypersensitivity may occur even with the first dose of a medication. The nurse must monitor for that possibility.

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