The nurse administers a medication to the patient.
Which symptoms indicate that the patient is having an allergic reaction rather than a side effect?
The patient correctly demonstrates the exercises and how to use the spirometer.
The patient explains to the nurse why the exercises and spirometer are important.
The patient will correctly demonstrate how to use pursed-lip breathing.
The patient’s pulse oximetry will stay greater than 94% with at least 12 breaths/minute.
The Correct Answer is A
The correct answer is E(None of the Above)
Rationale for E:
The options A, B, C, and D all describe actions or physiological measurements that do not directly indicate an allergic reaction.
Allergic reactions involve the immune system's response to a specific substance, whereas side effects are unintended reactions to a medication that are not caused by an immune response.
Key differences between allergic reactions and side effects:
Allergic reactions:
Typically occur rapidly after exposure to the allergen.
Can involve various body systems, including the skin (hives, itching, rash), respiratory system (wheezing, difficulty breathing, throat tightness), gastrointestinal system (nausea, vomiting, diarrhea), and cardiovascular system (low blood pressure, shock).
May be life-threatening in severe cases, such as anaphylaxis. Side effects:
Can occur at any time during medication use.
Usually more predictable and less severe than allergic reactions.
Often subside as the body adjusts to the medication or with dose adjustments. Important considerations for nurses:
Carefully assess patients for potential allergies before administering medications.
Monitor patients closely for any signs of allergic reactions or side effects after medication administration.
Promptly intervene if an allergic reaction is suspected, following established protocols and administering emergency medications as needed.
Document all observations and actions related to medication administration and patient responses.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice B rationale:
Heart rate: During a stress response, the sympathetic nervous system is activated, leading to a release of hormones such as adrenaline and cortisol. These hormones increase heart rate, preparing the body for a "fight or flight" response. A heart rate of 132 beats per minute is significantly elevated compared to a normal resting heart rate of 60-100 beats per minute, suggesting a stress response.
Choice C rationale:
Pupil dilation: Pupil dilation is another physiological change associated with the activation of the sympathetic nervous system during stress. The dilation allows more light to enter the eyes, enhancing visual acuity and awareness of surroundings, which can be helpful in responding to potential threats.
Choice E rationale:
Difficulty sleeping: Stress can negatively impact sleep in several ways. It can cause racing thoughts, anxiety, and physical tension, making it difficult to fall asleep and stay asleep. Sleep disturbances are a common symptom of stress and can further exacerbate its effects.
Rationale for incorrect choices:
Choice A: Blood glucose level can be affected by stress, but a low blood glucose level of 36 mg/dL is more likely to be due to other causes such as hypoglycemia or insulin therapy. It's not a direct indicator of a stress response.
Choice D: Blood pressure can increase during stress, but a blood pressure of 104/56 mmHg is within the normal range and does not necessarily indicate a stress response.
Correct Answer is D
Explanation
Choice A rationale:
Incorrect because swallowing the tablet with water would lead to slower absorption and a delayed onset of action. Nitroglycerin is rapidly absorbed through the oral mucosa, and swallowing it would route it through the digestive system, where it would be absorbed more slowly and less effectively.
Swallowing the tablet could also increase the risk of side effects, such as headache and flushing, due to the larger amount of the drug that would be absorbed systemically.
Choice B rationale:
Incorrect because crushing the tablet and dissolving it in water would also delay its absorption. This method would require the tablet to dissolve in the water before it could be absorbed through the oral mucosa, which would slow down the onset of action.
Crushing the tablet could also damage the medication and make it less effective.
Choice C rationale:
Incorrect because placing the tablet in the patient's mouth next to the cheek would not allow for optimal absorption. The oral mucosa under the tongue is more permeable than the cheek, so placing the tablet under the tongue allows for faster and more efficient absorption.
Placing the tablet in the cheek could also increase the risk of the patient accidentally swallowing it.
Choice D rationale:
Correct because placing the tablet under the patient's tongue allows for rapid absorption and a quick onset of action. The sublingual route is the preferred method of administration for nitroglycerin because it allows the medication to bypass the digestive system and be absorbed directly into the bloodstream.
This method also allows for the patient to easily remove the tablet if they experience any side effects.
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