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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. "Arrange to perform all nonessential tasks for the client at one time."
Grouping nonessential tasks reduces frequent disruptions, allowing the client to rest more effectively, which is essential for recovery.
B. "Encourage the client to sleep as much as possible during the day."
Excessive daytime sleeping can disrupt the client’s sleep-wake cycle, leading to difficulty sleeping at night.
C. "Perform routine hygiene for the client during the night."
Performing hygiene tasks at night can disturb the client’s rest and impact recovery.
D. "Remove limits on visiting hours for the client." Unrestricted visiting hours can increase noise and interruptions, making it harder for the client to get adequate rest.

A. A client was placed in the waiting room based on their triage assessment. B. A client was transferred to the inpatient antepartum unit to rule out preterm labor. C. A client was referred to the county hospital for medical screening evaluation. D. A stable client was transferred to a public hospital that provides reduced-cost care.

Correct Answer is C

Explanation

A. "A client was placed in the waiting room based on their triage assessment." Hospitals can prioritize clients based on triage assessment as long as they receive a medical screening examination and stabilizing treatment if necessary.
B. "A client was transferred to the inpatient antepartum unit to rule out preterm labor." EMTALA requires that hospitals evaluate and stabilize clients with emergency medical conditions, including preterm labor. Transferring a client within the same facility for further evaluation does not violate EMTALA.
C. "A client was referred to the county hospital for medical screening evaluation." Under EMTALA, hospitals must provide a medical screening examination and necessary stabilizing treatment before referring or transferring a client, regardless of their insurance status. Sending a client elsewhere for evaluation without treatment is a violation.
D. "A stable client was transferred to a public hospital that provides reduced-cost care." Once a client has been stabilized, hospitals may arrange for transfer to another facility, provided the transfer meets EMTALA guidelines and is in the client's best interest.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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