A nurse is assisting with the care of a client who is receiving penicillin via intermittent IV bolus.Which of the following should the nurse recognize as a clinical manifestation of anaphylaxis?

Peripheral edema.

Pallor.

Hypertension.

Pruritus.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Peripheral edema is swelling in the tissues due to fluid accumulation, often related to heart or kidney issues, not typically a sign of anaphylaxis.

Choice B rationale

Pallor refers to paleness and is usually a sign of anemia or shock, not specifically linked to anaphylaxis.

Choice C rationale

Hypertension, or high blood pressure, is not a common manifestation of anaphylaxis. Anaphylaxis typically causes hypotension, or low blood pressure.

Choice D rationale

Pruritus, or severe itching, is a common clinical manifestation of anaphylaxis due to the release of histamines in the body.

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Correct Answer is A

Explanation

Choice A rationale

Recent exposure to tuberculosis is the priority for the nurse to address because tuberculosis is a contagious and potentially serious infectious disease. Addressing this first helps prevent the spread of infection to other clients and healthcare staff.

Choice B rationale

While a history of generalized anxiety disorder is important, it is not the immediate priority compared to a contagious disease like tuberculosis. Anxiety can be managed with ongoing care and support.

Choice C rationale

Nocturia is a condition characterized by frequent urination at night and can indicate underlying health issues, but it is not an immediate priority compared to tuberculosis exposure.

Choice D rationale

Periodic migraine headaches can be debilitating and require management, but they do not pose an immediate risk to others like tuberculosis exposure does.

A. Increased respiratory rate. B. Positive Trousseau's sign. C. Tingling of the fingers. D. Dizziness upon standing.

Correct Answer is A

Explanation

Choice A rationale

Increased respiratory rate is a compensatory mechanism in metabolic acidosis to expel excess carbon dioxide and decrease blood acidity.

Choice B rationale

Positive Trousseau's sign indicates hypocalcemia, not metabolic acidosis. It is seen in patients with low calcium levels.

Choice C rationale

Tingling of the fingers is usually associated with electrolyte imbalances such as hypocalcemia, rather than metabolic acidosis.

Choice D rationale

Dizziness upon standing is typically a sign of orthostatic hypotension, not directly related to metabolic acidosis.

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A nurse is assisting with the care of a client who is receiving penicillin via intermittent IV bolus.Which of the following should the nurse recognize as a clinical manifestation of anaphylaxis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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