During antibiotic therapy, the nurse will monitor closely for signs and symptoms of a hypersensitivity reaction. Which of these assessment findings may be an indication of a hypersensitivity reaction? (Select all that apply.)

Shortness of breath

Black hairy tongue

Itching

Swelling of the tongue

Wheezing

Answer and Explanation

Correct Answer : A,C,D,E

Choice A rationale:

Shortness of breath is a common symptom of a hypersensitivity reaction. This occurs because the body’s immune system responds to a foreign substance, known as an antigen, by producing specific antibodies. This immune response can cause inflammation and swelling in various parts of the body, including the airways, leading to shortness of breath.

Choice B rationale:

A black hairy tongue is not typically associated with a hypersensitivity reaction. It is a condition that causes the tongue to appear black and hairy, and it’s usually caused by an overgrowth of bacteria or yeast on the tongue. It’s not related to allergies or hypersensitivity reactions.

Choice C rationale:

Itching is another common symptom of a hypersensitivity reaction. When the body encounters an antigen, it triggers an immune response that releases chemicals like histamine. Histamine can cause itching, among other symptoms.

Choice D rationale:

Swelling of the tongue can be a symptom of a severe hypersensitivity reaction known as anaphylaxis. This is a medical emergency that requires immediate attention. The swelling is caused by inflammation in response to an antigen.

Choice E rationale:

Wheezing is a symptom of a hypersensitivity reaction, specifically type I hypersensitivity. This type of reaction includes allergic disorders, which affect the lungs among other parts of the body. The immune response to an antigen can cause the airways to narrow and produce a wheezing sound.

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Correct Answer is ["2.5 "]

Explanation

Step 1: Identify the given values. The nurse needs to administer 2.5 mg of hydromorphone. The available amount is 5 mg/5 mL.

Step 2: Set up the calculation. We need to find out how many mL correspond to 2.5 mg. We can set up a proportion using the given values:

5 mL5 mg=x mL2.5 mg

Step 3: Solve for x. Cross-multiply and solve for x:

5 mg×x mL=2.5 mg×5 mL

Step 4: Simplify the equation:

x=5 mg.5 mg×5 mL

Step 5: Calculate the value of x:

x=2.5 mL

So, the nurse should administer 2.5 mL of the hydromorphone elixir.

A. Insulin is absorbed most rapidly when injected in the thigh. B. Use cold insulin for injection to minimize site pain. C. Massage the site after injection to promote absorption. D. Rotate the injection site to keep insulin levels consistent.

Correct Answer is D

Explanation

Choice A rationale:

Insulin is not absorbed most rapidly when injected in the thigh. The abdomen is actually the preferred site for insulin injection as insulin is absorbed more quickly and predictably there. The thigh is a simple area for self-injection, but regular injections in the thigh can sometimes cause discomfort when walking or running afterward.

Choice B rationale:

Using cold insulin for injection to minimize site pain is not recommended. Insulin should be at room temperature. Cold insulin might make the injection more painful.

Choice C rationale:

Massaging the site after injection to promote absorption is not advised. It can cause the insulin to be absorbed too quickly which can lead to low blood glucose levels.

Choice D rationale:

Rotating the injection site to keep insulin levels consistent is the correct choice. People who take insulin daily should rotate their injection sites. This is important because using the same spot over time can cause lipodystrophy. In this condition, fat either breaks down or builds up under the skin, causing lumps or indentations that interfere with insulin absorption.

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During antibiotic therapy, the nurse will monitor closely for signs and symptoms of a hypersensitivity reaction. Which of these assessment findings may be an indication of a hypersensitivity reaction? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer hydromorphone 2.5 mg. The available amount is 5 mg/5 mL elixir. How many mL should the nurse administer?

Correct Answer is ["2.5 "]

Explanation

A nurse is reinforcing teaching about insulin injections with a client who is newly diagnosed with type I diabetes mellitus. Which of the following information should the nurse include about site selection?

Correct Answer is D

Explanation

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