A nurse is teaching a client about reducing the risk for osteoporosis. Which of the following statements by the client indicates an understanding of possible anaphylaxis?
A feeling of swelling in the feet
Pain at the injection site
A sudden decrease in heart rate
A sharp decrease in blood pressure
The Correct Answer is D
A. A feeling of swelling in the feet: Swelling in the feet can be caused by various factors such as fluid retention, circulatory issues, or certain medical conditions like venous insufficiency. It is not a typical symptom of anaphylaxis, which usually involves more generalized symptoms such as hives, itching, swelling of the face or throat, difficulty breathing, and a drop in blood pressure.
B. Pain at the injection site: Pain at the injection site is a common side effect of receiving an injection or medication. It occurs due to tissue irritation or trauma from the needle. While allergic reactions can cause localized redness, swelling, or itching at the injection site, severe pain alone is not a hallmark symptom of anaphylaxis.
C. A sudden decrease in heart rate: Anaphylaxis typically leads to an increase in heart rate (tachycardia) rather than a decrease. This increase in heart rate is a response to the body's attempt to compensate for the drop in blood pressure caused by anaphylaxis. Bradycardia (a decrease in heart rate) is not a typical feature of anaphylaxis unless it occurs very late in a severe reaction due to profound circulatory collapse.
D. A sharp decrease in blood pressure: This choice is indicative of an understanding of possible anaphylaxis. Anaphylaxis can cause a rapid and severe drop in blood pressure, known as hypotension. This drop in blood pressure is often a key feature of anaphylaxis and can lead to symptoms such as dizziness, fainting, confusion, and shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Eyewear: Eyewear, such as goggles or a face shield, should be removed after the mask. Eyewear protects the eyes from exposure to infectious respiratory droplets or aerosols. When removing eyewear, the nurse should handle it by the sides and avoid touching the front surface, which may be contaminated.
B. Gloves: Gloves are the first item to be removed when leaving the client's room. This is because gloves are in direct contact with potentially contaminated surfaces or materials. Removing gloves first helps prevent the spread of pathogens from the gloves to other parts of the PPE or the nurse's skin.
C. Mask: After removing gloves, the nurse should remove the mask next. Masks are worn to protect the respiratory system from inhaling airborne infectious particles. When removing the mask, it's important to handle it by the straps or ties and avoid touching the front surface, which may have been exposed to pathogens.
D. Gown: The gown is the last item to be removed. Gowns provide coverage to protect clothing and skin from contamination. When removing the gown, it's important to do so carefully to avoid contaminating oneself or the surrounding environment.
Correct Answer is B
Explanation
A.Place the sterile field at the level of the nurse’s hips: This is not a recommended action. The sterile field should be placed at waist level or slightly above to ensure easy access and prevent contamination.
B. Hold bottles of sterile solution with the label in the palm of the hand: This protects the label from becoming wet and illegible, which is proper sterile technique.
C. Open the outermost flap of the sterile kit toward the body: When opening a sterile kit or package, the nurse should open the outermost flap away from the body to prevent contamination. Opening the flap toward the body increases the risk of airborne particles or contaminants from the nurse's clothing or skin entering the sterile field.
D. Sterile liquids should be poured into sterile containers on the sterile field, taking care not to contaminate the field.
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