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?
Pallor
Peripheral edema
Hypertension
Pruritus
The Correct Answer is D
Choice A: This is incorrect because pallor is not a sign of anaphylaxis. Pallor can indicate shock, anemia, or hypoxia.
Choice B: This is incorrect because peripheral edema is not a sign of anaphylaxis. Peripheral edema can indicate heart failure, kidney disease, or venous insufficiency.
Choice C: This is incorrect because hypertension is not a sign of anaphylaxis. Hypertension can indicate stress, pain, or renal disease.
Choice D: This is correct because pruritus is a sign of anaphylaxis. Pruritus is a severe itching sensation that can accompany hives, rash, or angioedema.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Delaying ambulation until the next day is not an appropriate intervention, as it can cause stiffness, muscle weakness, or joint contractures in the affected knee. The nurse should encourage regular exercise and activity within the client's tolerance level to maintain joint mobility and function.
Choice B reason: Applying moist heat prior to ambulation is an appropriate intervention, as it can reduce pain and inflammation in the affected knee by increasing blood flow and relaxing the muscles and tendons around the joint.
Choice C reason: Using a continuous passive motion machine is not an appropriate intervention for osteoarthritis, as it is mainly used after knee replacement surgery to prevent scar tissue formation and improve range of motion in the new joint.
Choice D reason: Restricting intake of dairy products is not an appropriate intervention for osteoarthritis, as dairy products are good sources of calcium and vitamin D that can support bone health and prevent osteoporosis. The nurse should advise the client to eat a balanced diet that includes fruits, vegetables, whole grains, lean protein, and low-fat dairy products.
Correct Answer is B
Explanation
Choice A reason: Blurred vision is not an expected side effect of digoxin, but a sign of digoxin toxicity, which requires immediate medical attention.
Choice B reason: This is the correct answer because digoxin can cause hypokalemia (low potassium levels), which increases the risk of digoxin toxicity. Therefore, clients taking digoxin need to have their potassium levels monitored regularly and consume foods rich in potassium.
Choice C reason: Antacids can interfere with the absorption of digoxin and reduce its effectiveness. Clients taking digoxin should avoid taking antacids within two hours of taking the medication.
Choice D reason: Weighing oneself every other day is not related to digoxin therapy, but to fluid balance. Clients with heart failure, who are often prescribed digoxin, need to monitor their weight daily and report any significant changes to their health care provider.
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