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 C
Explanation
Choice A rationale:
Irrigating with sterile saline before swabbing can dilute the wound specimen and reduce the accuracy of the culture results. This is because the saline can wash away some of the bacteria that are present in the wound, making it more difficult to identify the specific bacteria that are causing the infection.
Additionally, swabbing the center of the wound may not collect a representative sample of the bacteria present, as bacteria can often be found in higher concentrations at the edges of the wound. This is because the edges of the wound are often where the tissue is most damaged and where the bacteria are able to enter the body more easily.
Choice B rationale:
Obtaining a sample of the drainage from the dressing on the wound may not be as accurate as collecting a sample directly from the wound. This is because the drainage may contain bacteria from the surrounding skin or environment, which could contaminate the culture results.
Additionally, the drainage may not contain a representative sample of the bacteria present in the wound, as some bacteria may not be able to drain out of the wound.
Choice D rationale:
Collecting a tissue sample from the wound during a surgical procedure is the most accurate way to obtain a culture. However, this is not always feasible or necessary.
It is often possible to obtain an accurate culture by collecting a sample from the wound using a sterile swab. This is a less invasive procedure and can be done at the bedside.
Correct Answer is C
Explanation
Choice A rationale:
Loosening the tape gently by pressing the skin away from it is an important step in changing a burn dressing. However, it is not the first intervention that should be performed. This is because removing the tape can be painful, and it is important to ensure that the patient is adequately pain-free before proceeding.
Choice B rationale:
Observing the wound bed for the presence of granulation tissue is also an important part of burn care. Granulation tissue is a sign of healing, and its presence indicates that the wound is progressing as expected. However, this assessment is not the first priority when changing a dressing. Pain management should always be addressed first.
Choice D rationale:
Gently irrigating the wound using sterile normal saline is another important step in burn care. Irrigation helps to cleanse the wound and remove any debris or dead tissue. However, it should not be performed until the patient's pain has been adequately controlled.
Choice C rationale:
Administering pain medication 30 minutes beforehand is the most important first intervention when changing a painful burn dressing. This allows time for the medication to take effect and ensure that the patient is comfortable before the dressing change begins. Pain management is crucial in burn care, as it can help to reduce anxiety, promote healing, and improve patient outcomes.
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