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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?

A.

High-pitched wheezing

B.

Urticaria over the entire body

C.

Pruritis of the face

D.

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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Related Questions

Correct Answer is B

Explanation

A. Dose The dose (5 mg) is clearly stated.
B. Time The prescription does not specify the frequency (e.g., every 4 hours PRN pain). The nurse should clarify how often the medication should be given.
C. Medication The medication (morphine) is clearly stated.
D. Route The route (IV bolus) is clearly specified.

Correct Answer is ["A","B","C","D","E","F","G","H"]

Explanation

The key pieces of information that indicate the client is at risk for falls include:

  1. Admitted following a fall down approximately five steps – Indicates a recent fall history.
  2. Client's partner reports client possibly hit their head and was a little disoriented for a minute or two – Suggests potential confusion or altered mental status.
  3. Client has a history of falls and orthostatic hypotension per client's partner – A significant risk factor for future falls.
  4. Client uses a walker – Indicates mobility impairment.
  5. Client ordered new glasses following an eye exam last week but has not received them yet – Vision impairment increases fall risk.
  6. Blood pressure: Lying: 130/90 mm Hg, Sitting: 128/88 mm Hg, Standing: 98/60 mm Hg – Orthostatic hypotension (drop in BP upon standing) can cause dizziness and falls.

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