A nurse is caring for a client who just received a dose of IV ampicillin. Which of the following client reactions requires priority intervention by the nurse?
BP 98/62
Urticaria
Wheezing
Pulse rate 104/min
The Correct Answer is C
A. BP 98/62:
A blood pressure of 98/62 mmHg is within the normal range for an adult, although it's slightly lower than the average blood pressure. While monitoring blood pressure is important, this reading doesn't indicate a critical condition and doesn't require immediate intervention.
B. Urticaria:
Urticaria, also known as hives, is a skin rash characterized by raised, itchy welts. While it can be uncomfortable and may indicate an allergic reaction, it's not immediately life-threatening. However, it does warrant attention and further assessment.
C. Wheezing:
Wheezing is a high-pitched whistling sound that occurs during breathing and can indicate airway obstruction, such as in an allergic reaction or asthma exacerbation. Wheezing can be a sign of a severe allergic reaction or anaphylaxis, which requires immediate intervention to ensure the patient's airway remains open and to administer appropriate treatment.
D. Pulse rate 104/min:
A pulse rate of 104 beats per minute (bpm) is slightly elevated but within the normal range for an adult. While it's important to monitor heart rate, this finding alone doesn't indicate an immediate threat to the patient's life.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. An infection that is difficult to treat:
This choice describes a challenging infection but does not specifically capture the concept of a superinfection. While superinfections can indeed be difficult to treat, they are defined more specifically as secondary infections that occur due to disruption of the normal microbial flora during the treatment of an initial infection.
B. An infection caused by a weakened immune system:
This choice describes an infection that occurs due to a compromised or weakened immune system, which can indeed increase the risk of developing infections, including superinfections. However, it does not fully encompass the definition of a superinfection, which specifically involves the overgrowth of opportunistic pathogens after the disruption of normal microbial flora by antimicrobial treatment.
C. A secondary infection that occurs when microorganisms normally present in the body are killed by the drug:
This choice accurately describes what a superinfection is. It highlights the key concept that a superinfection is a secondary infection that arises when antimicrobial treatment disrupts or kills the normal microbial flora of the body, allowing opportunistic pathogens to overgrow and cause infection.
D. A drug-resistant infection:
This choice describes an infection caused by microorganisms that are resistant to the effects of antimicrobial drugs. While drug resistance is a significant concern in healthcare, it does not specifically define a superinfection. Superinfections can involve drug-resistant microorganisms, but they are not solely characterized by drug resistance; rather, they are secondary infections resulting from the disruption of normal microbial flora during antimicrobial treatment.
Correct Answer is B
Explanation
A.Green leafy vegetables:
There is no specific recommendation to avoid green leafy vegetables while taking tetracycline. However, it’s generally advisable to take tetracycline on an empty stomach, as certain foods and supplements containing calcium, magnesium, aluminum, iron, or zinc can interfere with the absorption of tetracycline if consumed concurrently. Green leafy vegetables are not typically high in these minerals, so there is no need to avoid them specifically.
B. Sunlight:
Tetracycline antibiotics, including Sumycin, can increase the skin’s sensitivity to sunlight and UV radiation, leading to an increased risk of sunburn and photosensitivity reactions. Therefore, clients taking tetracycline should be advised to minimize sun exposure, wear protective clothing, and use sunscreen with a high sun protection factor (SPF) to reduce the risk of sunburn and skin damage.
C. Exercise:
There is no specific contraindication to exercise while taking tetracycline. In fact, regular exercise can promote overall health and well-being. However, it’s essential for clients to listen to their bodies and avoid strenuous exercise if they experience any adverse effects or symptoms while taking tetracycline or any other medication.
D. Foods high in tyramine:
Tetracycline antibiotics do not interact with tyramine-containing foods in the same way as certain other classes of antibiotics, such as monoamine oxidase inhibitors (MAOIs). Therefore, there is no specific need to avoid foods high in tyramine while taking tetracycline, as tyramine-related interactions are not typically associated with tetracycline use.
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