A nurse is caring for a client who is receiving a first dose of amoxicillin. Which of the following findings should the nurse report to the provider immediately?
High-pitched wheezing
Urticaria over the entire body
Pruritis of the face
Rhinitis with clear discharge
The Correct Answer is A
A. High-pitched wheezing Wheezing indicates airway constriction, which is a sign of anaphylaxis, a life-threatening allergic reaction. This requires immediate intervention (e.g., stopping the medication, administering epinephrine, and providing oxygen).
B. Urticaria over the entire body While urticaria (hives) is a sign of an allergic reaction, it is not as urgent as airway compromise. It should still be reported but does not take immediate priority over wheezing.
C. Pruritis of the face Facial itching is a mild allergic reaction but does not indicate imminent airway compromise like wheezing does.
D. Rhinitis with clear discharge Nasal congestion or a runny nose can be a mild allergic reaction but is not an emergency.
Priority action: Apply the ABC (Airway, Breathing, Circulation) framework, which prioritizes airway compromise (wheezing) over skin-related allergic reactions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A nurse administers the wrong medication to a client. – This is an example of negligence, as it represents a failure to follow the standard of care, potentially causing harm to the client. Nurses are expected to follow the "five rights" of medication administration to prevent errors.
B. A nurse applies wrist restraints to a client in violation of the facility's restraint use policy. – This is an example of false imprisonment, not negligence, as it involves restricting a client’s movement without proper justification.
C. A nurse touches a client in an offensive manner. – This is an example of battery, which is the intentional act of touching someone without their consent in a harmful or offensive way.
D. A nurse shares information about a client with family members without the client's consent. – This is an example of a breach of confidentiality, violating HIPAA regulations.
Correct Answer is B
Explanation
A. "Speech therapist" –
A speech therapist helps clients with swallowing difficulties (dysphagia) and communication impairments but does not focus on activities of daily living (ADLs) like dressing and toileting.
B. "Occupational therapist" –
An occupational therapist assists clients in regaining independence with ADLs, such as dressing, toileting, and bathing, by teaching adaptive techniques and recommending assistive devices.
C. "Physical therapist" –
A physical therapist focuses on improving mobility, strength, and balance but does not specifically address dressing and toileting tasks.
D. "Recreational therapist" –
A recreational therapist works on improving the client’s quality of life through leisure activities and social engagement, not basic self-care tasks.
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