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?
Increased blood pressure
Hypertonia
Wheezing
Urinary retention
The Correct Answer is C
Choice A rationale: While increased blood pressure can occur in various conditions, it might not specifically indicate anaphylaxis to penicillin.
Choice B rationale: Hypertonia might not directly correlate with anaphylaxis and could be caused by other factors.
Choice C rationale: Wheezing is a critical sign of anaphylaxis, a severe allergic reaction to penicillin. Reporting wheezing to the provider is crucial for immediate intervention to prevent further complications associated with anaphylaxis.
Choice D rationale: Urinary retention is not a typical manifestation of anaphylaxis to penicillin and might not be directly linked to the allergic reaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: While increased blood pressure can occur in various conditions, it might not specifically indicate anaphylaxis to penicillin.
Choice B rationale: Hypertonia might not directly correlate with anaphylaxis and could be caused by other factors.
Choice C rationale: Wheezing is a critical sign of anaphylaxis, a severe allergic reaction to penicillin. Reporting wheezing to the provider is crucial for immediate intervention to prevent further complications associated with anaphylaxis.
Choice D rationale: Urinary retention is not a typical manifestation of anaphylaxis to penicillin and might not be directly linked to the allergic reaction.
Correct Answer is A
Explanation
Choice A rationale: Nasal cyanocobalamin for pernicious anemia is commonly administered once a week. The instruction to administer the medication into one nostril aligns with the correct technique.
Choice B rationale: Post-administration lying down isn't necessary for this medication.
Choice C rationale: The duration of treatment can vary; a fixed duration isn't universally applicable.
Choice D rationale: Using a nasal decongestant isn't a routine part of administering nasal cyanocobalamin for pernicious anemia.
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