A nurse in the emergency department is assisting in the care of a client.
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Nurses Notes
1630:
Called to client's room by emergency call bell. 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
Vital Signs
1630:
Temperature 38.3°C (101°F)
Heart rate 110/min
Respiratory rate 30/min
Blood pressure 90/55 mmHg
Oxygen saturation 91% on room air
Client is short of breath
intercostal retractions visible
Wheezing auscultated throughout lung fields
Diffuse, raised rash present on trunk
Respiratory rate 30/min
Blood pressure 90/55 mmHg
Oxygen saturation 91% on room air
Temperature 38.3°C (101°F)
Client is alert and oriented to person, place, and time.
Heart rate 110/min
The Correct Answer is ["A","B","C","D","E","F","G"]
- Shortness of breath. The client is experiencing respiratory distress, which could indicate a severe allergic reaction (anaphylaxis). Immediate intervention is needed to prevent airway compromise and respiratory failure.
- Intercostal retractions. Retractions occur when breathing is labored, suggesting airway obstruction or bronchoconstriction. This is a sign of worsening respiratory distress, requiring urgent medical attention.
- Wheezing auscultated throughout lung fields. Wheezing suggests bronchospasm, which is common in anaphylaxis and asthma attacks. The presence of diffuse wheezing indicates that the airways are narrowing, making breathing more difficult.
- Diffuse, raised rash present on trunk. A new-onset rash following antibiotic administration raises suspicion for anaphylaxis or a severe allergic reaction. Immediate treatment with antihistamines and corticosteroids may be required.
- Respiratory rate 30/min. The increased respiratory rate indicates that the client is compensating for airway constriction and hypoxia. This is an early warning sign of impending respiratory failure if not treated promptly.
- Blood pressure 90/55 mmHg. The drop in blood pressure suggests anaphylactic shock, where vasodilation and fluid leakage from capillaries lead to hypotension. Immediate administration of epinephrine is necessary to prevent cardiovascular collapse.
- Oxygen saturation 91% on room air. A decrease in oxygen saturation indicates impaired gas exchange, likely due to airway swelling and bronchospasm. Supplemental oxygen therapy should be provided to prevent further desaturation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Premedicate the client with diphenhydramine. Premedicating with diphenhydramine is not necessary unless the client has a history of mild allergic reactions to erythromycin. Erythromycin is a macrolide antibiotic and does not have significant cross-reactivity with penicillin, making premedication unnecessary.
B. Request a different route of administration from the provider. Changing the route of administration does not address concerns about allergy. Erythromycin is well tolerated in clients with a penicillin allergy, and there is no indication that a different route would be required unless the client has difficulty swallowing or gastrointestinal intolerance.
C. Administer the medication to the client. Erythromycin belongs to the macrolide class and is commonly prescribed as an alternative for clients allergic to penicillin. There is no cross-reactivity between macrolides and penicillins, making erythromycin a safe and effective option for treating bacterial infections in these clients.
D. Request a different medication from the provider. There is no need to request an alternative medication unless the client has a known allergy to erythromycin. Since macrolides are safe for clients with penicillin allergies, withholding the medication without a valid reason could delay necessary treatment.
Correct Answer is D
Explanation
A. Increased salivation. Tobramycin, an aminoglycoside antibiotic, does not cause increased salivation. It primarily affects the kidneys and auditory system, with no significant impact on saliva production. Increased salivation is more commonly associated with medications affecting the autonomic nervous system, such as cholinergic agents.
B. Bruising. While some antibiotics may impact platelet function, aminoglycosides like tobramycin do not commonly cause thrombocytopenia or increased bruising. Clients experiencing unexplained bruising should be evaluated for other underlying causes, such as coagulation disorders or concurrent medication use.
C. Joint pain. Joint pain is not a typical adverse effect of tobramycin. While some antibiotics, like fluoroquinolones, are associated with tendonitis or joint issues, aminoglycosides primarily affect the kidneys and inner ear, leading to nephrotoxicity and ototoxicity rather than musculoskeletal symptoms.
D. Tinnitus. Tobramycin is ototoxic and can cause tinnitus, hearing loss, or balance disturbances due to its toxic effects on the auditory and vestibular nerves. Clients receiving tobramycin should be monitored for early signs of ototoxicity, and the medication should be discontinued if symptoms develop to prevent permanent hearing damage.
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