A nurse is assessing a client who is receiving penicillin IV.
For which of the following findings should the nurse report to the provider as a manifestation of anaphylaxis?
Hypertonia.
Wheezing.
Urinary retention.
Increased blood pressure.
The Correct Answer is B
Anaphylaxis is a severe, potentially life-threatening allergic reaction that can occur within seconds or minutes of exposure to an allergen, such as penicillin.

One of the symptoms of anaphylaxis is wheezing, which is caused by the constriction of the airways and a swollen tongue or throat.
Choice A is wrong because hypertonia (increased muscle tone) is not a known symptom of anaphylaxis.
Choice C is wrong because urinary retention (inability to completely empty the bladder) is not a known symptom of anaphylaxis.
Choice D is wrong because increased blood pressure is not a known symptom of anaphylaxis; in fact, anaphylaxis can cause a sudden drop in blood pressure.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The first action the nurse should take is to assess the client for adverse reactions.
It is important to ensure the client’s safety and well-being before taking any further actions.
Choice A is wrong because filing an incident report is not the first action the nurse should take.
Choice B is wrong because determining factors that led to the omission is not the first action the nurse should take.
Choice D is wrong because reporting the missed dosage to the client’s provider is not the first action the nurse should take.
Correct Answer is B
Explanation
Warfarin is an oral anticoagulant medication and is not administered subcutaneously.
The nurse should clarify this prescription with the provider before administering it.
Choice A is wrong because tetracycline can be prescribed in doses of 1 g orally every 6 hours.
Choice C is wrong because Penicillin G can be prescribed in doses of 5,000,000 units intramuscularly every 4 hours.
Choice D is wrong because Zoledronate can be prescribed as a single intravenous dose of 5 mg.
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