A nurse is assessing a client following the administration of an initial dose of captopril. Which of the following findings indicates an anaphylactic response?
Laryngeal edema
Fever
Hypertension
Arrhythmia
The Correct Answer is A
Choice A reason: Laryngeal edema is a classic sign of anaphylaxis, a severe and potentially life-threatening allergic reaction. It can lead to difficulty breathing and requires immediate medical attention. Anaphylaxis can occur with any medication, including captopril, especially on initial exposure.
Choice B reason: Fever is not typically a sign of anaphylaxis. While it can be a symptom of various infections or inflammatory processes, it is not indicative of an immediate hypersensitivity reaction.
Choice C reason: Hypertension, or high blood pressure, is not a sign of anaphylaxis. In fact, during an anaphylactic reaction, blood pressure often drops significantly, a condition known as anaphylactic shock.
Choice D reason: Arrhythmia, or an irregular heartbeat, can be associated with various cardiac conditions but is not a specific indicator of anaphylaxis. While severe allergic reactions can affect heart rate, they are more likely to cause hypotension than arrhythmia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Administering oxygen at 2 L/min is appropriate for clients with emphysema who have hypoxemia. Oxygen therapy should be titrated based on the client's oxygen saturation levels to avoid suppressing the respiratory drive.
Choice B reason: The use of incentive spirometry is beneficial for clients with emphysema as it encourages deep breathing and helps prevent atelectasis. It is an appropriate intervention to include in the plan of care.
Choice C reason: Breathing exercises for clients with emphysema typically focus on prolonging the exhalation phase, not the inhalation phase, to improve airway clearance and reduce the work of breathing.
Choice D reason: Limiting fluid intake is not generally recommended for clients with emphysema unless there are specific contraindications. Adequate hydration can help thin secretions and improve mucus clearance.
Correct Answer is C
Explanation
Choice A reason: Epithelialization at the site of a major full-thickness burn would not be expected 12 hours post-injury. Epithelialization is a later stage of wound healing where new skin cells form and cover the wound. In full-thickness burns, this process is significantly delayed and typically requires skin grafting for wound closure.
Choice B reason: Severe pain is not typically associated with full-thickness burns due to the destruction of nerve endings in the skin. However, there may be severe pain in the surrounding areas that have sustained less severe burns.
Choice C reason: Edema is a common and expected finding at the site of a major full-thickness burn 12 hours post-injury. The inflammatory response to the burn injury leads to increased vascular permeability and fluid shift from the intravascular to the interstitial space, resulting in edema.
Choice D reason: Blistering is characteristic of partial-thickness burns (second-degree burns) but not full-thickness burns (third-degree burns). In full-thickness burns, the skin is destroyed to the point where blisters do not form.
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