A nurse in the emergency department is collecting data from a client who was admitted following a bee sting.
Which of the following findings should the nurse expect in a client who is experiencing anaphylaxis?

Increased deep tendon reflexes.

Erythema of the skin.

Bradycardia.

Hypotension.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Increased deep tendon reflexes are not typically associated with anaphylaxis. This is more commonly seen in conditions affecting the nervous system.

Choice B rationale:

While erythema of the skin can occur in anaphylaxis, it is not the most indicative symptom of this condition.

Choice C rationale:

Bradycardia is not typically associated with anaphylaxis. Anaphylaxis is more likely to cause tachycardia, or a rapid heart rate.

Choice D rationale:

Hypotension, or low blood pressure, is a common symptom of anaphylaxis. This occurs due to widespread vasodilation in response to the allergen.

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Correct Answer is B

Explanation

Choice A rationale:

While it’s important to start CPR as soon as possible, the AED should be attached as soon as it’s available.

Choice B rationale:

The American Heart Association recommends providing chest compressions at a rate of 100-120/min during CPR.

Choice C rationale:

Checking for a brachial pulse is not a priority during CPR. The focus should be on providing chest compressions and rescue breaths.

Choice D rationale:

The correct ratio of compressions to breaths during CPR is 30:2, not 50:2.

Correct Answer is ["1100"]

Explanation

The correct answer is 1100.

Calculation: The current time is 0700 and there are 300 mL remaining in the bag. The IV is infusing at a rate of 75 mL/hr. Therefore, 300 mL ÷ 75 mL/hr = 4 hours. Adding 4 hours to the current time of 0700 gives 1100.

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A nurse in the emergency department is collecting data from a client who was admitted following a bee sting.Which of the following findings should the nurse expect in a client who is experiencing anaphylaxis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who becomes unresponsive.While administering CPR, which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who is receiving IV dextrose 5% in 0.9% sodium chloride at 75 mL/hr. When the nurse checks the client's IV bag at 0700, 300 mL remain in the bag. At what time should the nurse hang a new bag of IV fluid? (Use the military format, four-digit number to enter the time.)

Correct Answer is ["1100"]

Explanation

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A nurse in the emergency department is collecting data from a client who was admitted following a bee sting.
Which of the following findings should the nurse expect in a client who is experiencing anaphylaxis?