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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Related Questions
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.
Correct Answer is A
Explanation
The nurse should administer the medication over 2 hr because amphotericin B lipid complex should be infused slowly intravenously.
Choice B is wrong because priming the tubing with 0.9% sodium chloride is not mentioned as a necessary action when administering amphotericin B lipid complex via intermittent IV bolus.
Choice C is wrong because discarding the medication if it is yellow is not mentioned as a necessary action when administering amphotericin B lipid complex via intermittent IV bolus.
Choice D is wrong because a gravity flow set is not mentioned as a necessary action when administering amphotericin B lipid complex via intermittent IV bolus.
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