A nurse is assessing a client following the administration of an initial dose of captopril. Which of the following findings indicates an anaphylactic response?

Laryngeal edema

Fever

Hypertension

Arrhythmia

Answer and Explanation

The Correct Answer is A

Choice A reason: Laryngeal edema is a classic sign of anaphylaxis, a severe and potentially life-threatening allergic reaction. It can lead to difficulty breathing and requires immediate medical attention. Anaphylaxis can occur with any medication, including captopril, especially on initial exposure.

Choice B reason: Fever is not typically a sign of anaphylaxis. While it can be a symptom of various infections or inflammatory processes, it is not indicative of an immediate hypersensitivity reaction.

Choice C reason: Hypertension, or high blood pressure, is not a sign of anaphylaxis. In fact, during an anaphylactic reaction, blood pressure often drops significantly, a condition known as anaphylactic shock.

Choice D reason: Arrhythmia, or an irregular heartbeat, can be associated with various cardiac conditions but is not a specific indicator of anaphylaxis. While severe allergic reactions can affect heart rate, they are more likely to cause hypotension than arrhythmia.

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Correct Answer is B

Explanation

Choice A reason: Droplet precautions are used for diseases that are transmitted through large respiratory droplets produced by coughing, sneezing, or talking. AIDS, caused by the Human Immunodeficiency Virus (HIV), is not transmitted through respiratory droplets, so droplet precautions are not necessary for a client with AIDS.

Choice B reason: Standard precautions are the primary strategy for the prevention of infection transmission and apply to all patients receiving care in hospitals, regardless of their diagnosis or presumed infection status. These precautions include hand hygiene, the use of personal protective equipment (PPE) like gloves and gowns, and safe injection practices. Since HIV/AIDS can be transmitted through blood and certain body fluids, standard precautions are essential when caring for clients with AIDS.

Choice C reason: Airborne precautions are used for diseases that are transmitted by small droplet nuclei that remain suspended in the air and can be widely dispersed by air currents within a room or over a long distance. HIV/AIDS is not transmitted through the airborne route, so airborne precautions are not indicated for clients with AIDS.

Choice D reason: Contact precautions are used for infections that are spread by direct contact with the patient or indirect contact with surfaces or patient care items. While HIV can be present in body fluids, it is not easily transmitted through casual contact. Therefore, contact precautions are not specifically required for clients with AIDS unless they have other conditions that warrant such precautions.

A. Perform a Mantoux skin test on the client. B. Assign the client to a negative-pressure airflow room. C. Wear a surgical mask when providing care to the client. D. Recommend that the client's family members receive antiviral therapy.

Correct Answer is C

Explanation

The correct answer is: c. Wear a surgical mask when providing care to the client.

Choice A: Perform a Mantoux skin test on the client

The Mantoux skin test is used to screen for tuberculosis, not pertussis. Pertussis, also known as whooping cough, is a bacterial infection caused by Bordetella pertussis. The Mantoux test would not be relevant or helpful in diagnosing or managing pertussis.

Choice B: Assign the client to a negative-pressure airflow room

Negative-pressure airflow rooms are typically used for airborne infections such as tuberculosis, measles, or varicella. Pertussis is primarily spread through respiratory droplets, not airborne transmission, so a negative-pressure room is not necessary.

Choice C: Wear a surgical mask when providing care to the client

Wearing a surgical mask is appropriate when caring for a client with pertussis. Pertussis is spread through respiratory droplets, and wearing a mask helps prevent the transmission of the bacteria to healthcare workers and other patients.

Choice D: Recommend that the client’s family members receive antiviral therapy

Antiviral therapy is not effective against pertussis, which is a bacterial infection. Instead, antibiotics such as azithromycin or erythromycin are used to treat pertussis and prevent its spread. Therefore, recommending antiviral therapy would not be appropriate.

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A nurse is assessing a client following the administration of an initial dose of captopril. Which of the following findings indicates an anaphylactic response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has AIDS. Which of the following isolation precautions should the nurse implement?

Correct Answer is B

Explanation

A nurse working in the emergency department is admitting a client who has pertussis. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

Choice A: Perform a Mantoux skin test on the client

Choice B: Assign the client to a negative-pressure airflow room

Choice C: Wear a surgical mask when providing care to the client

Choice D: Recommend that the client’s family members receive antiviral therapy

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