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: The nurse should not titrate TPN solution to blood pressure, as this can cause hypotension or hypertension.
Choice B rationale: The nurse should use an infusion pump to regulate the flow rate of TPN solution, not hang it to gravity, as this can cause over-infusion or under-infusion.
Choice C rationale: TPN is a form of nutrition that is delivered intravenously and provides all the essential nutrients for the client. TPN can cause fluid and electrolyte imbalances, infection, and hyperglycemia. Therefore, the nurse should monitor the client's weight daily to assess for fluid retention or loss, which can indicate overhydration or dehydration.
Choice D rationale: The nurse should also monitor the client's blood glucose level every 4 to 6 hours, not weekly, to detect and prevent hyperglycemia.
Correct Answer is D
Explanation
Choice A rationale: Taking spironolactone with or without food does not significantly affect its absorption.
Choice B rationale: Doubling the dose without consulting a healthcare provider can lead to adverse effects.
Choice C rationale: Using salt substitutes containing potassium might exacerbate hyperkalemia.
Choice D rationale: Spironolactone, a potassium-sparing diuretic, can increase potassium levels. Limiting potassium-rich foods is essential to prevent hyperkalemia, indicating an understanding of the teaching.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.