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 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.

A. Hold the drug, and administer 4 hours later. B. Administer the vancomycin as ordered. C. Hold the drug, and notify the prescriber. D. Repeat the test to verify results.

Correct Answer is C

Explanation

Choice A rationale:

Holding the drug and administering it 4 hours later is not the appropriate action. The trough vancomycin level of 24 mcg/mL is higher than the recommended range of 10-20 mcg/mL, indicating potential risk for toxicity. Administering the drug later does not address the immediate concern of a high trough level.

Choice B rationale:

Administering the vancomycin as ordered is not the correct action in this case. The trough level is above the recommended range, which could lead to vancomycin toxicity. The nurse should not administer the medication without addressing the high trough level. Choice C rationale:

This is the correct action. The nurse should hold the drug and notify the prescriber because the trough vancomycin level is higher than the recommended range. The prescriber can then make a decision based on this information, which may include adjusting the dose, extending the dosing interval, or ordering additional tests.

Choice D rationale:

While repeating the test to verify results might be done eventually, it should not be the immediate next step. The nurse has a responsibility to ensure patient safety, and with a trough level above the recommended range, the priority is to prevent potential toxicity. Therefore, the nurse should hold the drug and notify the prescriber.

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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

When teaching a patient a skill such as self-injection of insulin, what is the best way to set up the teaching/learning session?

Correct Answer is B

Explanation

The nurse checks the patient’s laboratory work prior to administering a dose of vancomycin and finds that the trough vancomycin level is 24 mcg/mL. What will the nurse do next?

Correct Answer is C

Explanation

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