A nurse in the emergency department is assisting in the care of a 50-year-old male client who presents with severe left ear pain.
Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.
A. Client is alert and oriented to person, place, and time.
B. Client is short of breath, intercostal retractions visible.
C. Wheezing auscultated throughout lung fields.
D. Diffuse, raised rash present on trunk.
E. Abdomen soft, nontender.
F. Temperature: 38.3°C (101°F)..
G. Heart rate: 110/min.
H. Respiratory rate: 30/min.
I. Blood pressure: 90/55 mm Hg.
J. Oxygen saturation: 91% on room air.
Client is alert and oriented to person, place, and time.
Client is short of breath, intercostal retractions visible.
Wheezing auscultated throughout lung fields.
Diffuse, raised rash present on trunk.
Abdomen soft, nontender.
Temperature: 38.3°C (101°F).
Heart rate: 110/min.
Respiratory rate: 30/min.
Blood pressure: 90/55 mm Hg.
Oxygen saturation: 91% on room air.
The Correct Answer is ["B","C","H","I","J"]
Choice A rationale: The client being alert and oriented to person, place, and time indicates that cerebral perfusion is currently adequate. This is a reassuring neurological finding and does not require immediate intervention. In the context of anaphylaxis, altered mental status would be more concerning, as it could indicate hypoxia or hypotension affecting cerebral function. Therefore, this finding does not necessitate urgent follow-up.
Choice B rationale: Shortness of breath with visible intercostal retractions indicates increased work of breathing and respiratory distress. In anaphylaxis, airway compromise due to bronchospasm or upper airway edema is life-threatening. Intercostal retractions reflect the use of accessory muscles to maintain ventilation, which is unsustainable and signals impending respiratory failure. Immediate intervention with epinephrine and airway support is critical to prevent hypoxia and respiratory arrest.
Choice C rationale: Wheezing throughout the lung fields suggests widespread bronchoconstriction, a hallmark of anaphylaxis. This occurs due to histamine and leukotriene release causing smooth muscle contraction in the airways. Persistent wheezing indicates ongoing airway obstruction and requires urgent treatment with intramuscular epinephrine, bronchodilators, and oxygen to reverse the reaction and prevent progression to complete airway closure.
Choice D rationale: A diffuse, raised rash (urticaria) is a common cutaneous manifestation of anaphylaxis but is not immediately life-threatening on its own. While it supports the diagnosis, it does not require urgent follow-up unless accompanied by airway or circulatory compromise. It is treated as part of the overall anaphylactic response but is not prioritized over respiratory or hemodynamic instability.
Choice E rationale: A soft, nontender abdomen is a normal finding and does not indicate any acute gastrointestinal or systemic pathology requiring urgent attention. In the context of anaphylaxis, abdominal symptoms such as cramping or vomiting may occur, but the absence of these signs here is reassuring. Therefore, this finding does not warrant immediate follow-up.
Choice F rationale: A temperature of 38.3°C (101°F) indicates a mild fever, which may be related to the underlying ear infection. However, it is not a critical finding in the context of anaphylaxis. Fever does not contribute to airway or circulatory compromise and does not require immediate intervention. It can be addressed after stabilizing the client’s acute allergic reaction.
Choice G rationale: A heart rate of 110/min represents mild tachycardia, which is a compensatory response to hypotension and hypoxia in anaphylaxis. While it supports the diagnosis, it is not the most urgent finding. Tachycardia alone does not require immediate follow-up unless it progresses to arrhythmia or is associated with hemodynamic instability, which is already reflected in the blood pressure and oxygen saturation.
Choice H rationale: A respiratory rate of 30/min is significantly elevated and indicates respiratory distress. In anaphylaxis, this may result from bronchospasm, hypoxia, or airway edema. Tachypnea is an early sign of respiratory compromise and must be addressed promptly to prevent respiratory failure. It reflects the body’s attempt to maintain oxygenation and acid-base balance under duress.
Choice I rationale: A blood pressure of 90/55 mm Hg is hypotensive and suggests distributive shock due to systemic vasodilation and increased vascular permeability in anaphylaxis. This is a critical finding requiring immediate administration of intramuscular epinephrine, IV fluids, and possibly vasopressors. Hypotension is a defining feature of anaphylactic shock and must be corrected to preserve organ perfusion.
Choice J rationale: An oxygen saturation of 91% on room air is below the normal range of 95–100% and indicates hypoxemia. In the setting of anaphylaxis, this may result from bronchospasm, airway edema, or impaired gas exchange. Hypoxemia is a life-threatening condition that necessitates immediate oxygen supplementation and treatment of the underlying allergic reaction to restore adequate oxygen delivery to tissues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Rationale for correct condition
Anaphylaxis is a severe, systemic hypersensitivity reaction characterized by rapid onset of airway compromise, hypotension, and skin/mucosal involvement. This client developed respiratory distress, hypotension (BP 90/55 mm Hg), tachycardia (HR 110/min), and a diffuse rash shortly after receiving cefdinir, a cephalosporin antibiotic. Given his known amoxicillin allergy, cross-reactivity with cephalosporins is plausible. The presence of wheezing and intercostal retractions indicates bronchospasm, a hallmark of anaphylaxis. Fever and ear pain are secondary and not the primary concern in this acute setting.
Rationale for correct actions
Epinephrine is the first-line treatment for anaphylaxis. It stimulates α1-adrenergic receptors to increase vascular tone and reverse hypotension, and β2-adrenergic receptors to cause bronchodilation and reduce airway edema. Intramuscular administration ensures rapid systemic absorption and is preferred over subcutaneous or intravenous routes in emergencies. Supplemental oxygen addresses hypoxemia due to bronchoconstriction and ventilation-perfusion mismatch. Oxygen saturation <92% indicates impaired gas exchange, and oxygen therapy improves tissue oxygenation while definitive treatment (epinephrine) takes effect. It also reduces the risk of hypoxic injury during systemic vasodilation and airway compromise.
Rationale for correct parameters
Oxygen saturation is a critical indicator of respiratory function. Normal SpO₂ is ≥95%; this client’s 91% suggests impaired oxygenation. Monitoring guides the effectiveness of oxygen therapy and identifies worsening bronchospasm or airway obstruction. Blood pressure must be monitored to assess for resolution of anaphylactic hypotension. Normal systolic BP is ≥100 mm Hg; persistent hypotension indicates ongoing vasodilation and need for further epinephrine or IV fluids. BP trends also help evaluate cardiovascular response to treatment.
Rationale for incorrect conditions
Acute asthma exacerbation lacks the systemic features (rash, hypotension) seen here and is not triggered by antibiotics. Acute otitis media explains ear pain and fever but not respiratory distress, rash, or hypotension. Angioedema may cause airway compromise but typically presents with localized swelling, not diffuse rash or hypotension.
Rationale for incorrect actions
Bronchodilator inhaler is useful in asthma but insufficient for anaphylaxis, which requires systemic treatment. Topical corticosteroid treats localized inflammation but is ineffective in systemic allergic reactions. Oral antibiotic is inappropriate during acute anaphylaxis and may worsen the reaction if allergenic.
Rationale for incorrect parameters
Blood glucose is not acutely affected in anaphylaxis and does not guide treatment. Peak expiratory flow rate is specific to asthma and not reliable during acute anaphylaxis. Temperature reflects infection but is not a priority in monitoring anaphylactic progression.
Take-home points
- Anaphylaxis presents with rapid-onset respiratory distress, hypotension, and skin findings after allergen exposure.
- Epinephrine is the cornerstone of treatment and must be administered promptly.
- Oxygen saturation and blood pressure are essential parameters to monitor during anaphylaxis.
- Differentiate anaphylaxis from asthma, otitis media, and angioedema based on systemic involvement and timing post-exposure.
Correct Answer is D
Explanation
Choice A rationale
Limiting potassium-containing foods is not typically indicated for patients on long-term prednisone. Prednisone, a corticosteroid, can cause hypokalemia by increasing renal potassium excretion, leading to a need for potassium supplementation or increased intake, not restriction, to maintain normal serum potassium levels (3.5-5.0 mEq/L) and prevent cardiac dysrhythmias.
Choice B rationale
Withholding prednisone for 48 hours prior to receiving contrast dye is unnecessary. This instruction is more pertinent to medications like metformin, which can interact with contrast dye and lead to lactic acidosis, particularly in clients with renal impairment, but it does not apply to prednisone.
Choice C rationale
Taking prednisone on an empty stomach is generally not recommended. Prednisone can cause gastric irritation, including dyspepsia and peptic ulcer disease, due to its prostaglandin inhibitory effects. Therefore, it is typically advised to take it with food or milk to minimize gastrointestinal upset and protect the gastric mucosa.
Choice D rationale
Prednisone, a glucocorticoid, elevates blood glucose levels by promoting gluconeogenesis and reducing peripheral glucose utilization, mimicking the effects of stress hormones. Long-term use can lead to steroid-induced hyperglycemia or even diabetes mellitus. Therefore, periodic monitoring of blood glucose is crucial to detect and manage this metabolic side effect, with normal fasting glucose being less than 100 mg/dL.
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