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 A
Explanation
A. "Are you having any difficulty breathing?":
Difficulty breathing is a critical symptom that may indicate a severe allergic reaction, such as anaphylaxis, which can be life-threatening. It is essential to assess for difficulty breathing immediately as it requires urgent intervention to ensure the patient's airway is clear and to administer appropriate treatment.
B. "Have you noticed any blood in your stool?":
While blood in the stool could indicate gastrointestinal bleeding, it is not typically associated with allergic reactions to antibiotics. This symptom is more commonly associated with other conditions such as gastrointestinal ulcers, infections, or inflammatory bowel disease. While important to assess, it is not as immediately concerning as difficulty breathing in the context of a suspected allergic reaction.
C. "Are you having difficulty with your hearing?":
Difficulty with hearing is not a common symptom of allergic reactions to antibiotics. It may be associated with other conditions such as ear infections or ototoxicity from certain medications. While it is important to assess any changes in hearing, it is not typically an immediate concern in the context of a suspected allergic reaction.
D. "Do you have a headache?":
Headaches are a common symptom that can occur for various reasons, including stress, tension, dehydration, or as a side effect of medications. While headaches can sometimes occur as a side effect of certain drugs, they are not typically associated with severe allergic reactions such as anaphylaxis. Therefore, while it is important to assess for headaches, it is not as immediately concerning as difficulty breathing in the context of a suspected allergic reaction.
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.
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