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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: A respiratory rate of 24/min is slightly higher than the normal range (12-20 breaths per minute) and does not necessarily indicate the effectiveness of furosemide in treating pulmonary edema.
Choice B reason: Adventitious breath sounds, such as crackles or wheezes, are often present in pulmonary edema and would not indicate that the furosemide is effective. The resolution of these sounds would be a better indicator of improvement.
Choice C reason: Weight loss of 1.8 kg (4 lb) in the past 24 hours likely indicates a reduction in fluid retention, which is a desired effect of furosemide in the treatment of pulmonary edema. This diuretic effect reduces the fluid overload, thereby improving the symptoms of pulmonary edema.
Choice D reason: An elevation in blood pressure is not an expected outcome of effective furosemide therapy for pulmonary edema. Furosemide is a diuretic and would more likely lead to a reduction in blood pressure due to fluid loss.
Correct Answer is C
Explanation
Choice A reason : A tongue blade should not be placed in the mouth during a seizure as it can cause injury or obstruct the airway.
Choice B reason: An NG tube, or nasogastric tube, is not typically required in the immediate management of seizures and should not be inserted during an active seizure due to the risk of injury.
Choice C reason: An oral airway may be used to maintain a patent airway during a postictal state if the client is unable to maintain their own airway.
Choice D reason: Wrist restraints are not routinely recommended for clients with seizure disorders as they can cause injury during a seizure. Safe environment and proper positioning are preferred to prevent injury.
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