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 B
Explanation
A. Bacteriostatics are narrow spectrum drugs, and bactericidal drugs are broad spectrum:
This statement is incorrect. The spectrum of activity (narrow vs. broad) of an antibiotic refers to the range of bacterial species that it can target, not whether it is bacteriostatic or bactericidal.
B. Bacteriostatic drugs inhibit bacterial growth, and bactericidal drugs actually kill bacteria:
This statement is correct. Bacteriostatic drugs work by inhibiting the growth and reproduction of bacteria without directly killing them, whereas bactericidal drugs directly kill bacteria.
C. Bacteriostatics work by inhibiting protein synthesis, and bactericidal drugs work by inhibiting nucleic acid synthesis:
This statement is incorrect. Both bacteriostatic and bactericidal drugs can target various bacterial cellular processes, including protein synthesis, nucleic acid synthesis, cell wall synthesis, and others. The mechanism of action is not a definitive factor in distinguishing between bacteriostatic and bactericidal drugs.
D. Bacteriostatic drugs actually kill bacteria, and bactericidal drugs inhibit bacterial growth:
This statement is incorrect. It contradicts the established definitions of bacteriostatic and bactericidal drugs. Bacteriostatic drugs inhibit bacterial growth without killing the bacteria, while bactericidal drugs directly kill bacteria.
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