A nurse is assessing a client who has anaphylactic shock due to a bee sting.

Which of the following findings should the nurse expect?

Bradycardia

Hypertension

Bronchospasm

Warm, dry skin.

Answer and Explanation

The Correct Answer is C

Bronchospasm.

Bronchospasm is a constriction of the airways that causes wheezing and trouble breathing. It is one of the symptoms of anaphylaxis, a severe allergic reaction that can occur within minutes of exposure to something you’re allergic to, such as a bee sting.

Choice A is wrong because bradycardia is a slow heart rate, not a fast one. Anaphylaxis causes a weak and rapid pulse due to low blood pressure.

Choice B is wrong because hypertension is high blood pressure, not low. Anaphylaxis causes blood pressure to drop suddenly and can lead to shock.

Choice D is wrong because warm, dry skin is not a sign of anaphylaxis. Anaphylaxis causes skin reactions such as hives, itching, flushed or pale skin.

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Correct Answer is A

Explanation

This is because phototherapy can damage the baby’s eyes and cause retinal injury.Eye pads should be used to protect the baby’s eyes from the light and should be removed every 4 hours to check for infection or injury.

Choice B is wrong because turning the lights off for ten minutes every hour would reduce the effectiveness of phototherapy and prolong the treatment time.Phototherapy aims to expose the baby’s skin to as much light as possible.

Choice C is wrong because clothing the baby in a shirt and diaper only would limit the amount of skin exposed to the light.The baby should be naked or wear only a diaper during phototherapy.

Choice D is wrong because tightly swaddling the baby in a baby blanket would also limit the amount of skin exposed to the light and increase the risk of overheating.The baby should be loosely wrapped or uncovered during phototherapy.

A. Initiate phototherapy immediately B. Notify the provider to order a serum bilirubin test C. Encourage the parent to feed the newborn more frequently D. Reassure the parent that this is a normal finding

Correct Answer is B

Explanation

Transcutaneous bilirubin measurement is a useful screening tool for neonatal hyperbilirubinemia, but it has some limitations and sources of variability.Therefore, any bilirubin screening result obtained must be confirmed by a diagnostic method before treatment.

Choice A is wrong because initiating phototherapy without confirming the bilirubin level could expose the newborn to unnecessary treatment and potential adverse effects.

Choice C is wrong because increasing hydration by feeding more frequently may not be sufficient to lower the bilirubin level if it is too high or if there are other causes of jaundice.

Choice D is wrong because reassuring the parent that this is a normal finding could delay the diagnosis and treatment of severe neonatal hyperbilirubinemia, which can lead to serious complications such as kernicterus spectrum disorders.

Normal ranges for transcutaneous bilirubin measurement vary depending on the device used, the skin pigmentation, and the postnatal age of the newborn.However, a general guideline is that a measurement of 16 mg/dL at 48 hours of age is above the 95th percentile and warrants further investigation.

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A nurse is assessing a client who has anaphylactic shock due to a bee sting. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

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A nurse is assessing a client who has anaphylactic shock due to a bee sting.

Which of the following findings should the nurse expect?