Which assessment data indicated to the nurse that a client is having an anaphylactic reaction to a medication?

Urticaria and pruritis.

Insomnia and irritability.

Tinnitus and diplopia.

Wheezing and dyspnea

Answer and Explanation

The Correct Answer is D

Anaphylaxis is a severe and potentially life-threatening allergic reaction that occurs rapidly after exposure to an allergen. The symptoms of anaphylaxis can vary but usually involve multiple organ systems, including the skin, respiratory, cardiovascular, and gastrointestinal systems.

Wheezing and dyspnea are two common symptoms of anaphylaxis that indicate the respiratory system's involvement.

Urticaria and pruritis are skin manifestations that can also be present in anaphylaxis, but they are not specific to this condition.

Insomnia and irritability are not typical symptoms of anaphylaxis.

Tinnitus and diplopia are also not common symptoms of anaphylaxis.

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Correct Answer is D

Explanation

The client is experiencing syncope (fainting) due to a drop in blood pressure to 70/40 mm Hg, which is too low. This suggests that the client's blood pressure medications are reducing their blood pressure too much, resulting in hypotension. The rationale for the nurse's decision to hold the client's scheduled antihypertensive medications is to prevent further hypotension and allow the client's blood pressure to stabilize at a safer level.

Option a is incorrect because diuresis (increased urine output) is not a likely cause of the client's hypotension.

Option b is incorrect because the client's symptoms suggest hypotension due to reduced blood pressure, rather than drug toxicity.

Option c is incorrect because the antagonistic interaction among blood pressure medications would result in reduced eﬀectiveness but would not necessarily cause hypotension.

A. Administer both prescribed medications as scheduled. B. Hold the calcitriol but administer the calcium carbonate as scheduled. C. Hold the calcium carbonate but administer the calcitriol as scheduled. D. Hold both medications until contacting the healthcare provider.

Correct Answer is D

Explanation

A total calcium level of 14 mg/dL (3.5 mmol/L) is higher than the normal range of 2.2 to 2.6 millimoles per liter (mmol/L)1. Calcitriol and calcium carbonate are both medications used to increase calcium levels in the blood2. Since the client’s calcium level is already high, it would be important for the nurse to hold both medications and contact the healthcare provider for further instructions.

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Which assessment data indicated to the nurse that a client is having an anaphylactic reaction to a medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who receives multiple antihypertensive multiple medications experiences syncope due to a drop in blood pressure to 70/40 mm Hg. Which is the rationale for the nurse’s decision to hold the client’s scheduled antihypertensive medications?

Correct Answer is D

Explanation

Prior to administering oral doses of calcitriol and calcium carbonate to a client with hypoparathyroidism, the nurse notes that the total level of calcium is 14 mg/dL (3.5 mmol/L). Which action should the nurse implement?

Correct Answer is D

Explanation

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