Shortly after providing a new sleeping pill to a patient on the medical unit, the nurse answers the patient's call light. Which of the following findings would indicate to the nurse that the patient is experiencing an anaphylactic reaction to the medication?

The patient complains of shortness of breath

The patient reports feeling hot, and her face appears flushed.

The patient states that she feels nauseated and has a headache.

The patient complains of continued wakefulness and agitation.

Answer and Explanation

The Correct Answer is A

A. The patient complains of shortness of breath: Shortness of breath is a hallmark symptom of an anaphylactic reaction. It indicates that the patient may be experiencing airway constriction, which is a medical emergency.

B. The patient reports feeling hot, and her face appears flushed: Flushing and a feeling of warmth can be early signs of an allergic reaction, but they are not specific to anaphylaxis. Other more severe symptoms would need to be present to diagnose anaphylaxis.

C. The patient states that she feels nauseated and has a headache: Nausea and headache are not typically associated with anaphylaxis. They may be side effects of the medication but are not indicative of an allergic reaction severe enough to cause anaphylaxis.

D. The patient complains of continued wakefulness and agitation: Continued wakefulness and agitation could be side effects of the sleeping pill but are not symptoms of an anaphylactic reaction. These symptoms do not require immediate emergency intervention like anaphylaxis would.

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Correct Answer is A

Explanation

A. Ensure that the skin is clean and dry. Cleaning and drying the skin removes dirt, oils, and moisture that could impede the absorption of the medication. This is the first step to ensure maximum efficacy of the topical ointment.

B. Don gloves prior to administration. While wearing gloves is important for infection control and personal protection, it does not directly facilitate the absorption of the ointment into the patient's skin.

C. Take the patient's vital signs. Checking vital signs is a general nursing practice but is unrelated to the application of topical ointments and does not affect absorption.

D. Apply to non-irritated areas of the skin. Applying to non-irritated skin is important to avoid exacerbating skin issues, but it’s not the first step to facilitate absorption. Ensuring the skin is clean and dry takes precedence.

A. Standing orders B. STAT orders C. Automatic stop orders D. Verbal orders

Correct Answer is A

Explanation

A. Standing orders: Standing orders are prewritten orders for specific situations. For a patient post-procedure, standing orders might include pain management protocols that would be activated based on the pain assessment.

B. STAT orders: STAT orders are urgent and are typically used in emergency situations. A pain score of 5/10 does not usually warrant a STAT order.

C. Automatic stop orders: Automatic stop orders are used to discontinue a medication after a certain period or dosage has been reached. They don’t apply directly to managing current pain levels.

D. Verbal orders: Verbal orders are given in person or over the phone when a written order is not possible. These should be minimized to avoid errors and are less likely to be used for routine pain management.

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Shortly after providing a new sleeping pill to a patient on the medical unit, the nurse answers the patient's call light. Which of the following findings would indicate to the nurse that the patient is experiencing an anaphylactic reaction to the medication?

Nursing Test Bank

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