A nurse is assessing a client who received an IM antibiotic injection 15 min ago. Which of the following findings should the nurse identify as an indication of a possible anaphylactic reaction to the medication?
A feeling of swelling in the feet
Pain at the injection site
A sudden decrease in heart rate
A sharp decrease in blood pressure
The Correct Answer is D
A. A feeling of swelling in the feet:
Swelling in the feet is not a typical sign of an anaphylactic reaction to an IM antibiotic injection. Anaphylaxis usually involves more rapid and widespread symptoms that can affect various body systems.
B. Pain at the injection site:
Pain at the injection site is a common side effect of intramuscular (IM) injections and is not typically indicative of an anaphylactic reaction. Anaphylactic reactions are characterized by more systemic and severe symptoms.
C. A sudden decrease in heart rate:
An anaphylactic reaction typically involves an increase in heart rate rather than a decrease. The body's response to an allergen in an anaphylactic reaction often includes a rapid heart rate, as part of the systemic release of inflammatory mediators.
D. A sharp decrease in blood pressure:
This is the correct answer. Anaphylactic reactions can lead to a sudden and severe drop in blood pressure, which is a critical and life-threatening symptom. This is due to the release of vasodilatory substances and increased permeability of blood vessels, resulting in a decrease in blood volume within the vessels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Schedule a support session for the client.While providing emotional support is important, it is not the immediate priority. The client needs to understand how to communicate effectively after the laryngectomy.
B. Review the use of an artificial larynx with the client.This intervention is the priority because the client will need to know how to use an artificial larynx to facilitate communication after losing their natural voice. This understanding is critical for the client’s post-operative adjustment and ability to express themselves.
C. Explain the techniques of esophageal speech.Although teaching esophageal speech is important, the use of an artificial larynx may be more immediately relevant and easier for the client to learn and use right after surgery.
D. Determine the client's reading ability.This may be relevant for assessing the client's ability to understand written instructions, but it is not as directly related to their immediate post-operative needs for communication.
Correct Answer is B
Explanation
Correct answer: B
A. Use a quick-release knot to secure the ties:
This is not the best practice. Quick-release knots are not recommended for securing tracheostomy ties because they can loosen more easily, increasing the risk of accidental decannulation (dislodging the tracheostomy tube). The ties should be securely fastened with a non-quick-release knot.
B. Cut the old ties after the new ties are secured:
This is the safest approach. It ensures the tracheostomy tube remains secure throughout the change.
C. Allow space for three fingers under the ties when securing:
Two fingers is the recommended space to allow for breathing comfort and prevent the tube from being too loose..
D. Extend the client's neck while securing the ties:
This is not the correct action. Hyperextending the client's neck during tracheostomy tie changes can cause discomfort and may compromise the integrity of the tracheostomy tube placement. The neck should be in a neutral position to maintain proper alignment.
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