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.

Answer and Explanation

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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Correct Answer is D

Explanation

Heparin therapy is used to prevent thrombus propagation and distal embolization while allowing the endogenous fibrinolytic system to dissolve existing clots in deep-vein thrombosis (DVT)1.

A reduction in calf circumference may indicate that the clot is dissolving and the therapy is effective.

Choice A is wrong because platelets within the expected reference range do not necessarily indicate that heparin therapy for DVT is effective.

Choice B is wrong because INR (International Normalized Ratio) is used to monitor warfarin therapy, not heparin therapy.

Choice C is wrong because the presence of pedal pulses bilaterally does not necessarily indicate that heparin therapy for DVT is effective.

A. Occipital headache. B. Fever. C. Excessive salivation. D. Myoclonic seizure.

Correct Answer is C

Explanation

Neostigmine is an anticholinesterase inhibitor that indirectly stimulates both nicotinic and muscarinic receptors by interfering with the breakdown of acetylcholine.

Stimulation of muscarinic receptors can lead to increased salivation.

Choice A is wrong because an occipital headache is not a manifestation of a muscarinic response to neostigmine.

Choice B is wrong because fever is not a manifestation of a muscarinic response to neostigmine.

Choice D is wrong because a myoclonic seizure is not a manifestation of a muscarinic response to neostigmine.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is receiving heparin therapy for deep-vein thrombosis. Which of the following findings should indicate to the nurse that the therapy is effective?

Correct Answer is D

Explanation

A nurse is caring for a client who received neostigmine 1 hr ago and is experiencing a muscarinic response. Which of the following manifestations should the nurse expect?

Correct Answer is C

Explanation

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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?