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:
The statement “I will wrap the suction catheters in a clean towel to be used again at a later time” is incorrect. Suction catheters should be disposed of after each use to prevent infection. Reusing catheters, even if wrapped in a clean towel, can introduce bacteria into the tracheostomy site, leading to potential infections.
Choice B Reason:
The statement “I will set the suction pressure dial between 80 and 120” is correct. The recommended suction pressure for adults is typically between 80 and 120 mmHg. This range is sufficient to effectively clear secretions without causing trauma to the tracheal mucosa. Setting the suction pressure within this range ensures safe and effective suctioning.
Choice C Reason:
The statement “I will suction for less than 15 seconds while inserting the suction catheter” is incorrect. Suctioning should be performed intermittently and for no longer than 10-15 seconds at a time. However, suctioning should not occur while inserting the catheter. Suction should be applied only while withdrawing the catheter to minimize trauma to the tracheal mucosa.
Choice D Reason:
The statement “I will suction the mouth before inserting the suction catheter into the tracheostomy” is incorrect. Suctioning the mouth before the tracheostomy can introduce oral bacteria into the tracheostomy site, increasing the risk of infection. The correct procedure is to suction the tracheostomy first and then the mouth if needed.
Correct Answer is C
Explanation
Choice A reason: Using NSAIDs for pain relief is not a risk factor for osteoporosis. NSAIDs are nonsteroidal anti-inflammatory drugs that are used to treat pain and inflammation. They do not affect bone density or calcium metabolism.
Choice B reason: Age 45 years is not a risk factor for osteoporosis. Osteoporosis is more common in older adults, especially postmenopausal women, but it can affect anyone at any age. The risk of osteoporosis increases with age, but it is not determined by a specific age.
Choice C reason: Smoking cigarettes is a risk factor for osteoporosis. Smoking can reduce bone mass and increase bone loss by interfering with the production and activity of estrogen, which is a hormone that protects bone health. Smoking can also impair blood circulation and oxygen delivery to the bones, which can affect their growth and repair.
Choice D reason: Regular aerobic exercise is not a risk factor for osteoporosis. Aerobic exercise is a type of physical activity that increases the heart rate and improves cardiovascular fitness. Aerobic exercise can also benefit bone health by stimulating bone formation and increasing bone density. Aerobic exercise can also prevent falls and fractures by improving balance and coordination.
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