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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 C

Explanation

Choice A rationale
A DNR prescription does not mean that the patient will only receive pain medication for their treatments. A DNR order simply means that if the patient’s heart stops beating or they stop breathing, medical staff will not attempt resuscitation3.
Choice B rationale
A DNR prescription does not necessarily limit a patient’s current treatment regimen. It only specifies that CPR will not be performed in the event of cardiac or respiratory arrest. Other treatments can still be provided based on the patient’s wishes and the medical team’s recommendations3.
Choice C rationale
A DNR prescription allows a patient to continue with their current treatment regimen. The DNR order only comes into effect if the patient’s heart stops or they stop breathing3.
Choice D rationale
While a DNR prescription may limit the ability to receive invasive procedures in the event of cardiac or respiratory arrest, it does not limit other forms of treatment. The patient can still receive treatments that align with their goals of care3.

A. You can get hepatitis C by coming into contact with an infected person’s bodily fluids, such as saliva. B. You can get hepatitis C by coming into contact with infected blood, such as from a used needle. C. You can get hepatitis C by consuming contaminated food or water. D. You can get hepatitis C by sharing personal items like toothbrushes or razors with an infected person.

Correct Answer is B

Explanation

Choice A rationale
Hepatitis C is not typically transmitted through saliva. It is a bloodborne virus, meaning it is most commonly transmitted through exposure to infected blood.
Choice B rationale
Hepatitis C is most commonly transmitted through exposure to infected blood. This can occur through sharing drug injection equipment, receiving a tattoo or piercing at a place with poor infection control, and other ways. Coming into contact with infected blood, such as from a used needle, is a common way the virus is transmitted.
Choice C rationale
Hepatitis C is not typically transmitted through consuming contaminated food or water. It is a bloodborne virus.
Choice D rationale
While it is possible to contract Hepatitis C by sharing personal items like toothbrushes or razors with an infected person, this is less common. The virus is most commonly transmitted through exposure to infected blood.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a terminal illness asks the nurse, “If I have a DNR prescription, does that mean I will no longer receive any treatment for my condition?” Which of the following statements should the nurse provide to explain a DNR prescription?

Correct Answer is C

Explanation

A nurse is educating a client newly diagnosed with hepatitis C. Which statement from the nurse best describes how the virus is transmitted?

Correct Answer is B

Explanation

Following an explosion at a local chemical lab, several people have sustained burns and are now in the triage area. Which patient should be attended to first?

A patient arrives at the emergency department with a stab wound to the chest. The healthcare provider places two chest tubes to drain air and blood from the patient’s thoracic cavity. Where should the nurse place the system?

The nurse is instructing the client on the correct way to take nitroglycerin as needed for chest pain. Which is the correct instruction?

Which laboratory finding is commonly associated with acute pancreatitis?

A patient has recently had a cast applied to their left lower extremity. Which of the following is included in the nursing care of this fresh cast?

A nurse is planning care for a client who has a peptic ulcer and a new prescription for sucralfate 2 gm administered twice daily. When should the nurse plan to administer the medication?

A nurse is assessing a client with a major burn injury. Which of the following findings should the nurse prioritize?

A patient has severe trauma from an automobile accident. The nurse is checking the gastric pH and is administering Protonix 40 mg IV piggyback two times a day as ordered. This is prophylactic to prevent which of the following?