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. Take small amounts of food:
This advice suggests eating small, frequent meals when experiencing diarrhea. It aims to reduce the workload on the digestive system and may help alleviate symptoms such as nausea and discomfort. However, while eating small amounts of food can be beneficial, increasing fluid intake is the priority to prevent dehydration associated with diarrhea.
B. Consume large quantities of milk and smoked meat:
Consuming large quantities of milk and smoked meat is not recommended when experiencing diarrhea. Dairy products, including milk, can worsen diarrhea in some individuals, especially those who are lactose intolerant. Similarly, smoked meat may be high in fat and difficult to digest, potentially aggravating gastrointestinal symptoms. Therefore, this advice is not appropriate for managing diarrhea.
C. Increase fluid intake:
Increasing fluid intake is essential when experiencing diarrhea to prevent dehydration. Diarrhea leads to the loss of fluids and electrolytes from the body, which can quickly lead to dehydration if not replenished. Encouraging the patient to drink water, clear broths, oral rehydration solutions, and other electrolyte-rich fluids helps replace lost fluids and maintain hydration levels, making this the correct choice.
D. Take a mild medication to treat the diarrhea along with the ciprofloxacin:
While it may be tempting to take a medication to alleviate diarrhea symptoms, it's crucial to consult a healthcare provider before taking any additional medications, especially when already taking antibiotics like ciprofloxacin. Some anti-diarrheal medications can interfere with the effectiveness of antibiotics or worsen gastrointestinal symptoms. Therefore, it's important to seek medical advice before taking any additional medications.
Correct Answer is ["A","B","D"]
Explanation
A.Recognizing the role of spirituality in health and healing:
Many CAM therapies acknowledge the importance of spirituality in health and healing. Spiritual well-being is considered an integral aspect of overall health in many CAM modalities. Practices such as meditation, yoga, and mindfulness often incorporate spiritual elements. Therefore, recognizing the role of spirituality in health and healing is a common characteristic of CAM therapies.
B. Focusing on treatment of the person as an individual:
One of the key principles of CAM therapies is treating the individual as a whole, taking into account physical, mental, emotional, and spiritual aspects of health. CAM practitioners often emphasize personalized care tailored to the unique needs and characteristics of each individual. Therefore, focusing on the treatment of the person as an individual is a common characteristic of CAM therapies.
C. Focusing only on physical health:
This statement is incorrect. Unlike conventional Western medicine, which primarily focuses on the physical aspects of health and disease, CAM therapies often take a holistic approach that considers the interconnectedness of the mind, body, and spirit. Therefore, CAM therapies typically address physical, mental, emotional, and spiritual aspects of health, rather than focusing solely on physical health.
D.Promotion of disease prevention, self-care, and self-healing:
Many CAM therapies emphasize the importance of disease prevention, self-care practices, and the body’s innate ability to heal itself. These therapies often encourage individuals to take an active role in maintaining their health and well-being through lifestyle modifications, stress management techniques, dietary changes, and other self-care practices. Therefore, promotion of disease prevention, self-care, and self-healing is a common characteristic of CAM therapies.
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