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 C
Explanation
A. Grasps the catheter 10.16 to 12.7 cm (4 to 5 in) from the tip The catheter should be held at least 5 to 7.6 cm (2 to 3 inches) from the tip to maintain better control and prevent contamination.
B. Cleanses the meatus using a clean cotton ball Aseptic technique requires a separate antiseptic swab or cotton ball for each stroke to avoid introducing bacteria.
C. Cleanses the meatus from the center in a circular motion Cleaning from the center outward prevents introducing bacteria into the urethra, which is essential for infection prevention.
D. Applies clean gloves before beginning the procedure Sterile gloves, not clean gloves, must be used during catheterization to maintain aseptic technique.
Correct Answer is D
Explanation
A. "I should close all doors and windows on the unit." –
This action is part of the "C" (Confine) step, which should be done before attempting to extinguish the fire.
B. "I should evacuate clients who are in immediate danger." –
Rescuing clients is the first step and should be done immediately.
C. "I should activate the facility's fire alarm system." –
Activating the alarm is the second step after rescuing clients.
D. "I should extinguish small fires if it is safe to do so." –
Extinguishing the fire is the last action in the fire safety protocol and should only be attempted if the fire is small and controllable.
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