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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should monitor the client for fever as an indication that the client is experiencing an acute infusion reaction to IV amphotericin
Fever is a common symptom of an infusion reaction to amphotericin
Choice A is wrong because pedal edema is not a commonly reported symptom of an acute infusion reaction to amphotericin
Choice C is wrong because hyperglycemia is not a commonly reported symptom of an acute infusion reaction to amphotericin
Choice D is wrong because dry cough is not a commonly reported symptom of an acute infusion reaction to amphotericin
Correct Answer is C
Explanation
The nurse should instruct the client to administer the medication through clothing if necessary.
In an emergency, an epinephrine auto-injector can be given through clothing.
Choice A is wrong because massaging the site after injection is not mentioned as something to avoid in the instructions for using an epinephrine auto-injector.
Choice B is wrong because the medication should be injected into the outer thigh, not the abdomen.
Choice D is wrong because aspiration prior to administration of the medication is not mentioned as a necessary step in the instructions for using an epinephrine auto-injector.
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