Exam NCLEX-RN topic 4 question 124 discussion

Actual exam question from Test Prep's NCLEX-RN

Question #: 124
Topic #: 4

A school-age child with asthma is ready for discharge from the hospital. His physician has written an order to continue the theophylline given in the hospital as an oral home medication. Immediately prior to discharge, he complains of nausea and becomes irritable. His vital signs were normal except for tachycardia. What first nursing actions would be essential in this situation?

A. Hold the child’s discharge for 1 hour.
B. Notify the physician immediately.
C. Discharge the child as the physician ordered.
D. Administer an antiemetic as necessary.

Show Suggested Answer

Suggested Answer: B 🗳️
(A) Holding the childs discharge alone does not address the clients problem. (B) Nausea, tachycardia, and irritability are all symptoms of theophylline toxicity. The physician should benotified immediately so that a serum theophylline level can be ordered. Theophylline dose should be withheld until the physician is notified. (C)
The child must be evaluated for theophylline toxicity before any discharge. (D) Cause of the nausea should be investigated before the administration of an antiemetic.

by [deleted] at March 10, 2025, 6:50 a.m.

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