A nurse in the emergency department is collecting data from a client who was admitted following a bee sting.
Which of the following findings should the nurse expect in a client who is experiencing anaphylaxis?

Increased deep tendon reflexes.

Erythema of the skin.

Bradycardia.

Hypotension.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Increased deep tendon reflexes are not typically associated with anaphylaxis. This is more commonly seen in conditions affecting the nervous system.

Choice B rationale:

While erythema of the skin can occur in anaphylaxis, it is not the most indicative symptom of this condition.

Choice C rationale:

Bradycardia is not typically associated with anaphylaxis. Anaphylaxis is more likely to cause tachycardia, or a rapid heart rate.

Choice D rationale:

Hypotension, or low blood pressure, is a common symptom of anaphylaxis. This occurs due to widespread vasodilation in response to the allergen.

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Correct Answer is B

Explanation

Choice A rationale:

Repeating the potassium level is not the first action to take. The nurse already has a recent lab value.

Choice B rationale:

The nurse should withhold the medication. The normal range for potassium is 3.5-5.0 mEq/L. A level of 5.5 mEq/L is high, so giving more potassium could lead to hyperkalemia.

Choice C rationale:

Monitoring for paresthesia is important in hyperkalemia, but it is not the first action. The nurse should first prevent further increase in potassium levels.

Choice D rationale:

Administering a hypertonic solution is not relevant in this situation. It does not directly address the high potassium level.

A. Tachycardia. B. Diminished urine output. C. Cold clammy skin. D. Unconsciousness.

Correct Answer is A

Explanation

Choice A rationale:

Tachycardia, or a rapid heart rate, is a common early sign of hypovolemic shock as the body tries to compensate for the decreased blood volume by increasing the heart rate.

Choice B rationale:

Diminished urine output is a sign of hypovolemic shock, but it is not typically an early sign.

Choice C rationale:

Cold, clammy skin is a sign of hypovolemic shock, but it is not typically an early sign.

Choice D rationale:

Unconsciousness is a late sign of hypovolemic shock, indicating severe blood loss and inadequate perfusion to the brain.

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A nurse in the emergency department is collecting data from a client who was admitted following a bee sting.Which of the following findings should the nurse expect in a client who is experiencing anaphylaxis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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A nurse in the emergency department is collecting data from a client who was admitted following a bee sting.
Which of the following findings should the nurse expect in a client who is experiencing anaphylaxis?