A nurse is assessing a client who is receiving penicillin IV.
For which of the following findings should the nurse report to the provider as a manifestation of anaphylaxis?
Hypertonia.
Wheezing.
Urinary retention.
Increased blood pressure.
The Correct Answer is B
Anaphylaxis is a severe, potentially life-threatening allergic reaction that can occur within seconds or minutes of exposure to an allergen, such as penicillin.

One of the symptoms of anaphylaxis is wheezing, which is caused by the constriction of the airways and a swollen tongue or throat.
Choice A is wrong because hypertonia (increased muscle tone) is not a known symptom of anaphylaxis.
Choice C is wrong because urinary retention (inability to completely empty the bladder) is not a known symptom of anaphylaxis.
Choice D is wrong because increased blood pressure is not a known symptom of anaphylaxis; in fact, anaphylaxis can cause a sudden drop in blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Ranitidine is a histamine H2-receptor antagonist that blocks histamine-mediated gastric acid secretion.

Antacids can interfere with the absorption of ranitidine, so it is important to separate their administration by at least 1 hour.
Choice A is wrong because aspirin is a type of nonsteroidal anti-inflammatory drug (NSAID) which can increase the risk of peptic ulcers.
Choice C is wrong because fine hand tremors are not a known side effect of ranitidine.
Choice D is wrong because there is no need to avoid dairy products when taking ranitidine.
Correct Answer is C
Explanation
The correct answer is C. "I should stay upright for at least 15 minutes after taking this medication."
Choice A rationale:
Black stools are a common side effect of iron supplements and do not usually require notification of the provider unless accompanied by other symptoms such as pain or gastrointestinal bleeding.
Choice B rationale:
Iron supplements should not be taken with milk because calcium can interfere with the absorption of iron, reducing its effectiveness.
Choice C rationale:
Staying upright for at least 15 minutes after taking ferrous gluconate helps prevent the risk of esophageal irritation or discomfort, which indicates the client's correct understanding of this key instruction.
Choice D rationale:
Taking an antacid with ferrous gluconate is not recommended because antacids can interfere with the absorption of iron, reducing its efficacy.
Choice E rationale:
This is the same as Choice D and also incorrect for the same reason regarding the interaction between antacids and iron absorption.
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