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
Fentanyl buccal film is a small film that sticks to the inside of the cheek and eventually dissolves within 15 to 30 minutes after it is applied.
It is used to manage breakthrough pain in patients with cancer who are already using another opioid pain medicine around-the-clock.
Choice A is wrong because the medication should not be placed on the client’s tongue for dissolution.
Choice B is wrong because the medication should not be dissolved in water before administering it.
Choice D is wrong because the client should not be instructed to swallow the medication with a sip of water.
Correct Answer is C
Explanation
- A. Assist the client to a left lateral position.
- This is generally used for clients at risk of aspiration, and it's not indicated based on the lithium level.
- B. Implement fluid restrictions.
- Fluid restrictions are usually implemented when there is a risk of fluid overload or hyponatremia, and not in this case. In fact, dehydration can raise lithium levels to toxic levels, so proper hydration is important.
- C. Request a dosage increase from the provider.
- While 0.6 mEq/L is within the therapeutic range, some providers may want to see a level slightly higher for maintenance. So requesting a dosage increase from the provider is the correct action.
- D. Prepare the client for hemodialysis.
- Hemodialysis is used to remove lithium from the blood in cases of severe lithium toxicity, which is indicated by levels significantly higher than 1.5 mEq/L. This is not needed when the lithium level is 0.6 mEq/L.
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