A postoperative patient is undergoing antibiotic therapy. She has never had any problems taking medications in the past. When the nurse hung the second dose of IV antibiotics, the patient suddenly developed hives and itching. The nurse recognized this was most likely a(n):

allergic reaction.

side effect.

toxic effect.

idiosyncratic reaction.

Answer and Explanation

The Correct Answer is A

A. An allergic reaction is an immune response to a medication, even if the patient has taken the medication before without issues. Symptoms like hives and itching are classic signs of an allergic reaction.
B. A side effect is an expected, often mild and predictable reaction to a medication, not typically involving an immune response and severe symptoms like hives.
C. A toxic effect refers to harmful effects from a medication overdose or accumulation in the body, not sudden onset after an appropriate dose.
D. An idiosyncratic reaction is an uncommon response not related to allergies or toxic effects, usually not presenting with hives and itching.

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Correct Answer is ["C","D","E"]

Explanation

A. Bilateral breath sounds clear and present throughout at 1600 are normal findings and do not require immediate follow-up.
B. The temperature at both 1600 (37.6°C) and 1630 (37.5°C) is slightly elevated but not critically high. It does not require immediate follow-up unless it worsens significantly or is accompanied by other concerning symptoms.
C. Urticaria (hives) over the chest and trunk, along with itching and difficulty swallowing (dysphagia), are signs of an allergic reaction, which requires immediate follow-up and assessment.
D. The blood pressure decreased to 78/52 mm Hg at 1630 from 110/58 mm Hg at 1600. This significant drop indicates hypotension and requires immediate follow-up.
E. Difficulty swallowing (dysphagia) reported by the client suggests a potential airway compromise and requires immediate follow-up to assess the severity and intervene accordingly.

A. ask the patients their names B. ask another nurse about their identities C. check the patients' ID bands and patient information D. verify their names with the family members

Correct Answer is C

Explanation

A. Asking patients their names can help, but it is not the most reliable method, especially if patients are confused or unable to communicate.
B. Asking another nurse about their identities can introduce errors and is not a standard practice for patient identification.
C. Checking the patients' ID bands and patient information ensures accurate identification using multiple identifiers (e.g., name, birth date, medical record number), adhering to best practices for patient safety.
D. Verifying names with family members can be helpful but is not as reliable or standardized as checking ID bands and patient information.

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A postoperative patient is undergoing antibiotic therapy. She has never had any problems taking medications in the past. When the nurse hung the second dose of IV antibiotics, the patient suddenly developed hives and itching. The nurse recognized this was most likely a(n):

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client Exhibits Select the 3 findings that require immediate follow-up.

Correct Answer is ["C","D","E"]

Explanation

Upon receiving the assignment for the evening, a nurse notices that two of the patients have the same name. The best way to identify two patients on a medical unit who have the same name is to:

Correct Answer is C

Explanation

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