A nurse is caring for a school-age child who has acute otitis media and a new prescription for clindamycin. Which of the following findings indicates the child is experiencing an allergic reaction to the medication?
Urticaria.
Conjunctivitis.
Temperature 38°C (100.4°F).
Cool extremities.
The Correct Answer is A
Choice A rationale:
Urticaria, commonly known as hives, is a skin rash characterized by raised, red, and itchy welts that can vary in size and shape. It is a classic manifestation of an allergic reaction. Allergic reactions can occur in response to medications like clindamycin. Urticaria is a result of histamine release and can range from mild to severe, with itching being a prominent symptom. The appearance of urticaria in a child taking clindamycin suggests a potential allergic reaction to the medication.
Choice B rationale:
Conjunctivitis, or pink eye, is inflammation of the conjunctiva, the clear membrane that covers the white part of the eye and lines the inner surface of the eyelids. While conjunctivitis can be associated with allergies, it is not a typical sign of an allergic reaction to clindamycin. Conjunctivitis is more commonly associated with eye irritation, redness, and discharge.
Choice C rationale:
A temperature of 38°C (100.4°F) alone is not a definitive sign of an allergic reaction to medication. Fever can be caused by a variety of factors, including infections, inflammatory processes, and other non-allergic reactions. While fever can be a symptom of an allergic reaction in some cases, it is not as specific as urticaria in indicating an allergic response.
Choice D rationale:
Cool extremities are not a classic sign of an allergic reaction to medication. Allergic reactions typically involve skin manifestations like hives, itching, and redness. Cool extremities might suggest poor peripheral circulation or decreased blood flow to the extremities, but they are not directly indicative of an allergic reaction to clindamycin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Positioning the child sitting with their buttocks at the edge of the table is not appropriate for collecting a bone marrow specimen from a preschooler. This position does not provide adequate access to the bone marrow aspiration site and may lead to discomfort for the child.
Choice B rationale:
Placing the child in a prone position (lying face down) is suitable for collecting a bone marrow specimen from a preschooler. This position exposes the posterior iliac crest, which is a common site for bone marrow aspiration. It allows for easier access to the bone marrow and reduces the risk of injury.
Choice C rationale:
Positioning the child side-lying to expose the vertebrae is not the recommended position for bone marrow aspiration. The iliac crest, not the vertebrae, is the usual site for this procedure in children. Placing the child in a side-lying position would make it difficult to access the appropriate site.
Choice D rationale:
Placing the child supine with legs flexed outward into a frog-like position is suitable for collecting a bone marrow specimen. This position provides access to the iliac crest while allowing for better immobilization of the child. It also ensures the child's safety and comfort during the procedure.
Correct Answer is D
Explanation
Answer: d. Apply suction in 3 to 4-second increments.
Rationale:
- a. Instill 2 mL of 0.9% sodium chloride prior to suctioning:While saline instillations may be used in some cases,it is not universally recommended for infants with tracheostomies and depends on the specific situation and healthcare provider's protocol.The priority in this case is to quickly clear the partial mucus occlusion to prevent respiratory distress.
- b. Select a catheter that fits snugly into the tracheostomy tube:This isincorrect.Selecting a catheter that fits tightly can damage the delicate tracheal mucosa and increase the risk of bleeding.A smaller-diameter catheter that allows for gentle passage is preferred.
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Tracheostomy tube and different catheter sizes
- c. Use a clean technique when performing suctioning:This is absolutely essential for all suctioning procedures to minimize the risk of infection.However,it is not the specific action that addresses the immediate concern of clearing the partial mucus occlusion.
- d. Apply suction in 3 to 4-second increments:This is thecorrectapproach for suctioning an infant with a tracheostomy.Applying short,intermittent suction bursts minimizes the risk of hypoxia and tissue trauma while effectively removing secretions.
Therefore, the most important action for the nurse to take is to apply suction in short, 3-4 second bursts to effectively clear the mucus occlusion while minimizing risks to the infant.
Additional Points:
- The nurse should use sterile suction equipment and sterile technique throughout the procedure.
- The suction pressure should be set at the lowest effective level,typically 80-120 mmHg.
- The nurse should monitor the infant for signs of respiratory distress,such as increased work of breathing,retractions,and oxygen desaturation,before,during,and after suctioning.
- If the mucus occlusion is not cleared after several attempts,the nurse should seek assistance from ahealthcareprovider.
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