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 D
Explanation
A. Doxycycline:
Doxycycline is a tetracycline antibiotic that is effective against anthrax. It is commonly used for post-exposure prophylaxis and treatment of anthrax infections.
B. Penicillin:
Penicillin is not typically the first-line antibiotic for treating anthrax. While some strains of Bacillus anthracis may be susceptible to penicillin, other antibiotics like doxycycline or ciprofloxacin are preferred due to their broader spectrum of activity and better penetration into tissues.
C. Oxytetracycline (Terramycin):
Oxytetracycline is another tetracycline antibiotic similar to doxycycline. Like doxycycline, oxytetracycline is effective against anthrax and can be used for post-exposure prophylaxis and treatment of anthrax infections.
D. Ciprofloxacin:
Ciprofloxacin is a fluoroquinolone antibiotic that is effective against anthrax. It is commonly used as an alternative to doxycycline for post-exposure prophylaxis and treatment of anthrax infections, particularly for individuals who cannot tolerate tetracyclines.
Correct Answer is A
Explanation
A. The patient stops taking the drug when he or she begins to feel better:
This choice refers to the common habit where patients discontinue their prescribed medication once they start to feel improvement in their symptoms, even if they haven't completed the full course of treatment. This premature cessation of medication can leave some microbes alive and potentially resistant to the antibiotic, allowing them to regrow and cause a recurrence of the infection.
B. The patient switches to multiple drug therapy from single drug therapy:
This choice describes a scenario where a patient switches from a single drug therapy to multiple drug therapy. While this may be a valid treatment approach in some cases, it is not directly related to the re-population and re-establishment of microbes causing an infection.
C. The patient uses OTC drugs prophylactically:
This choice involves patients using over-the-counter (OTC) drugs preventively without consulting a healthcare professional. While OTC drugs may have their own set of issues, such as contributing to antibiotic resistance, this behavior isn't specifically linked to the re-population and re-establishment of microbes causing an infection.
D. The patient increases the drug dosage when he or she perceives that the therapeutic effect of the drug is slowing down:
This choice describes a scenario where a patient independently increases the dosage of their medication without consulting a healthcare provider. While inappropriate dosage adjustments can lead to adverse effects, it doesn't directly address the re-population and re-establishment of microbes causing an infection.
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