The nurse notes that the patient is scratching and has hives 2 hours after receiving a dose of antibiotic medication.
The patient soon starts having difficulty breathing and his blood pressure drops. What is the correct analysis of the patient’s condition?
The patient is experiencing a moderate allergic reaction and should improve shortly.
These symptoms are probably due to food poisoning because very few patients have true allergic responses.
The patient is having an anaphylactic reaction and emergency interventions should be started.
The patient is having a mild reaction that can be treated easily with an antihistamine.
The Correct Answer is C
Rationale for Choice A:
Incorrect. While the patient is experiencing an allergic reaction, it is not moderate. The presence of difficulty breathing and a drop in blood pressure are signs of a severe, life-threatening anaphylactic reaction.
Anaphylaxis is a severe, rapid-onset allergic reaction that can lead to death if not treated promptly. It typically involves multiple body systems, including the skin, respiratory system, cardiovascular system, and gastrointestinal system.
Moderate allergic reactions typically present with localized symptoms such as hives, itching, and redness. They do not typically involve respiratory or cardiovascular compromise.
Rationale for Choice B:
Incorrect. The patient's symptoms are not consistent with food poisoning. Food poisoning typically causes gastrointestinal symptoms such as nausea, vomiting, diarrhea, and abdominal cramps. It does not typically cause hives, difficulty breathing, or a drop in blood pressure.
The timing of the symptoms, occurring 2 hours after receiving an antibiotic, strongly suggests an allergic reaction to the medication.
Rationale for Choice C:
Correct. The patient's symptoms are consistent with anaphylaxis, a severe allergic reaction that requires immediate emergency treatment.
Key features of anaphylaxis include:
Skin involvement (hives, itching, flushing, swelling)
Respiratory distress (difficulty breathing, wheezing, tightness in the chest) Cardiovascular compromise (drop in blood pressure, lightheadedness, fainting) Gastrointestinal symptoms (nausea, vomiting, diarrhea)
Swelling of the tongue or throat
Rationale for Choice D:
Incorrect. The patient's reaction is not mild and cannot be treated with an antihistamine alone. Antihistamines are effective for mild allergic reactions, but they are not sufficient to treat anaphylaxis.
Anaphylaxis requires immediate treatment with epinephrine, which is a life-saving medication that can reverse the effects of the allergic reaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Aspirating prior to injecting enoxaparin is not recommended.
Aspiration was once a common practice to check if a needle had entered a blood vessel.
However, research has shown that aspiration is not necessary for subcutaneous injections and may even be harmful. It can cause pain, bruising, and hematoma formation.
Additionally, aspirating can increase the risk of needlestick injuries.
For these reasons, aspiration is no longer recommended for subcutaneous injections of enoxaparin or other anticoagulants.
Choice B rationale:
Massaging the injection site after administering enoxaparin is not recommended. Massaging can increase the risk of bruising and hematoma formation.
It can also cause the medication to be absorbed too quickly, which can increase the risk of bleeding.
The best practice is to apply gentle pressure to the injection site with a dry gauze pad for a few seconds after the injection. This will help to prevent bleeding and bruising.
Choice C rationale:
The size of the syringe and needle used to administer enoxaparin is not specified in the question. However, a 1-mL syringe with a 32-gauge needle is a common choice for subcutaneous injections.
This size syringe is small enough to be easy to handle, and the 32-gauge needle is thin enough to minimize discomfort.
Choice D rationale:
The abdomen is the preferred site for subcutaneous injections of enoxaparin.
The abdomen has a large surface area of soft tissue, which makes it easy to inject the medication.
The abdomen is also relatively free of blood vessels and nerves, which reduces the risk of bruising, bleeding, and pain. Other potential injection sites for enoxaparin include the upper arms, thighs, and buttocks.
However, the abdomen is generally the preferred site.
Correct Answer is B
Explanation
Choice A rationale:
A patient's last bowel movement being 4 days ago does not directly increase their risk of pulmonary embolism (PE). While constipation can be a risk factor for deep vein thrombosis (DVT), which can lead to PE, it is not a significant risk factor on its own.
It's important to assess for other risk factors for DVT, such as immobility, recent surgery, or a history of blood clots, in conjunction with constipation.
Choice C rationale:
A platelet count of 45,000/mm^3 is low (thrombocytopenia), but it does not directly increase the risk of PE.
In fact, a low platelet count can sometimes hinder clot formation. However, it's important to monitor patients with thrombocytopenia for bleeding risks, as they may be more prone to bleeding complications.
Choice D rationale:
While receiving a transfusion of two units of packed red blood cells can increase blood viscosity, which could theoretically slightly increase the risk of PE, it is not a major risk factor.
Patients who receive transfusions are often already at an elevated risk of PE due to other underlying conditions or surgeries. It's essential to assess for other risk factors in these patients.
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