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A nurse is assisting with the care of a client.

At 1600, the nurse administered an antibiotic as prescribed.

At 1630, the nurse noted that the client’s bilateral breath sounds were clear and present throughout.

The client reports itching on the chest and has urticaria over the chest and trunk.

The client states they are having difficulty swallowing and feel as if there is a lump in their throat.

The nurse hears bilateral breath sounds with scattered wheezing throughout.

What should the nurse do next?

Stop the antibiotic infusion immediately and notify the healthcare provider.

Apply a cool compress to the itchy areas and monitor for further reactions.

Administer diphenhydramine (Benadryl) as a first-line treatment.

Assess the client’s throat for swelling and encourage them to drink water.

Answer and Explanation

The Correct Answer is A

A. Stop the antibiotic infusion immediately and notify the healthcare provider.

Explanation: This is the correct first action. The client is showing signs of a severe allergic reaction, possibly anaphylaxis. Stopping the antibiotic prevents further exposure to the allergen, and notifying the provider ensures prompt medical intervention.

B. Apply a cool compress to the itchy areas and monitor for further reactions.

Explanation: While a cool compress may help with itching, it does not address the serious symptoms of anaphylaxis, such as difficulty swallowing and wheezing. Immediate action is required beyond just symptom management.

C. Administer diphenhydramine (Benadryl) as a first-line treatment.

Explanation: While antihistamines like diphenhydramine are helpful in treating mild allergic reactions, this case suggests anaphylaxis, which requires epinephrine as the first-line treatment. Administering diphenhydramine alone is not sufficient for airway compromise.

D. Assess the client’s throat for swelling and encourage them to drink water.

Explanation: Assessing for throat swelling is important, but encouraging oral intake is not appropriate when a client has difficulty swallowing, as this could worsen airway obstruction. The priority is stopping the medication and seeking emergency intervention.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Choice A rationale
The vital signs presented in this choice are within the normal range. A blood pressure of 118/76 mm Hg is considered normal. A heart rate of 92/min is slightly elevated but still within the normal range (60-100 beats per minute). A temperature of 38.1° C (100.6° F) indicates a slight fever, which could be a response to an infection or inflammation. An oxygen saturation of 95% on room air is within the normal range (95%-100%).
Choice B rationale
The vital signs presented in this choice indicate that the patient may be experiencing a respiratory issue. A blood pressure of 126/84 mm Hg is slightly elevated but still within the acceptable range. A heart rate of 104/min is high, indicating that the heart is working harder than normal. A respiratory rate of 24/min is also high, suggesting that the patient may be having difficulty breathing. A temperature of 38.5 C (101.3* F) indicates a fever, which could be a response to an infection. An oxygen saturation of 92% on room air is below the normal range (95%-100%), suggesting that the patient is not getting enough oxygen. This is the vital sign that should be addressed first.

A. Electrical burns usually cause much more skin damage than what can be seen on your skin. B. Electrical burns can have small amounts of skin damage, but more extensive damage beneath the skin. C. Electrical burns commonly cause reddened/purplish skin without blistering. D. Electrical burns typically are minor.

Correct Answer is B

Explanation

Choice A rationale
While it’s true that electrical burns can cause more skin damage than what can be seen on the skin, this statement does not fully address the client’s misconception about the severity of their burn.
Choice B rationale
This is the best response because it directly addresses the client’s misconception and provides accurate information. Electrical burns can indeed have small amounts of skin damage but cause more extensive damage beneath the skin. This is because the electrical current can pass through the body and damage internal tissues and organs, even if the visible wound on the skin is small.
Choice C rationale
While electrical burns can cause reddened or purplish skin, they do not typically cause blistering. Furthermore, this statement does not address the client’s misconception about the severity of their burn.
Choice D rationale
This statement is incorrect. Electrical burns are not typically minor. They can cause serious internal injuries and complications, even if the visible wound on the skin is small.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Given the following vital signs, which should the nurse address first in the patient?

Correct Answer is B

Explanation

A nurse is caring for a client with an electrical burn. The client states that since the wound on the skin is small, the burn must not be too bad. Which of the following is the best response by the nurse?

Correct Answer is B

Explanation

A nurse is educating a patient with osteoporosis who has been prescribed alendronate 70 mg PO weekly (Fosamax). Which statement by the patient indicates a need for further instruction?

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A nurse is caring for a client who is to maintain a fluid restriction of 1,200 mL/24 hr. How many mL of fluids can the client have over the next 20 hr if the client had a total fluid intake of 300 mL during the first 4 hr of the shift?

A patient with aplastic anemia is scheduled to receive an injection of erythropoietin (Epogen). The patient inquires about the purpose of the injection. How should the nurse respond?

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The nurse is caring for an 85-year-old patient with septic shock. What should the nurse consider when repositioning this patient?

A nurse is educating a patient newly diagnosed with iron deficiency anemia. Which of the following would be a component of the education?