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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Providing written pamphlets for instruction can be a useful supplement, but it may not be the most effective method for teaching a skill like self-injection of insulin. This is because it lacks the hands-on practice and immediate feedback that can be crucial for learning a new physical skill.
Choice B rationale:
After demonstrating the procedure, allowing the patient to do several return demonstrations is considered one of the best methods for teaching a skill like self-injection of insulin. This approach, often referred to as “see one, do one, teach one,” allows the patient to observe the correct technique, practice it themselves, and then demonstrate their understanding by teaching it back. This method is particularly effective because it engages the patient in active learning and provides opportunities for immediate feedback and correction.
Choice C rationale:
Showing a video and allowing the patient to practice as needed on his own can be helpful, but it may not be as effective as other methods. This is because it lacks the immediate feedback and personalized instruction that can be provided in a one-onone teaching session. Additionally, practicing “as needed” may not provide the consistent repetition needed to master a new skill.
Choice D rationale:
Verbally explaining the procedure and providing written handouts for reinforcement can be effective, but it may not be sufficient for teaching a skill like self-injection of insulin. This is because it lacks the hands-on practice that is crucial for learning a new physical skill. Additionally, relying solely on verbal explanation and written handouts may not address all learning styles.
Correct Answer is D
Explanation
Choice A rationale:
Administering the antibiotic dose before obtaining the cultures could potentially affect the results of the cultures. Antibiotics are designed to kill or inhibit the growth of bacteria, so administering them before obtaining the cultures could lead to false negatives. This could lead to incorrect or delayed diagnosis and treatment.
Choice B rationale:
While obtaining the urine culture before administering the antibiotic dose is a good step, it should not be done before obtaining the blood culture. Blood cultures are usually obtained before urine cultures because they can help identify bacteria or fungi in the blood. This can be crucial in diagnosing conditions like sepsis. Furthermore, administering the antibiotic dose before obtaining the blood culture could affect the results of the culture.
Choice C rationale:
Obtaining the blood culture before administering the antibiotic dose is a good step, but the urine culture should also be obtained before the antibiotic dose is administered. Administering the antibiotic dose before obtaining all necessary cultures could affect the results of the cultures and lead to incorrect or delayed diagnosis and treatment.
Choice D rationale:
This is the correct sequence of actions. The nurse should first obtain both blood and urine cultures before administering the antibiotic dose. This is because the antibiotic could potentially kill or inhibit the growth of bacteria, which could affect the results of the cultures. By obtaining the cultures first, the healthcare team can ensure they are getting accurate results that have not been influenced by the antibiotics. This can lead to a more accurate diagnosis and more effective treatment plan.
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