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?
Increased blood pressure
Hypertonia
Wheezing
Urinary retention
The Correct Answer is C
Choice A rationale: While increased blood pressure can occur in various conditions, it might not specifically indicate anaphylaxis to penicillin.
Choice B rationale: Hypertonia might not directly correlate with anaphylaxis and could be caused by other factors.
Choice C rationale: Wheezing is a critical sign of anaphylaxis, a severe allergic reaction to penicillin. Reporting wheezing to the provider is crucial for immediate intervention to prevent further complications associated with anaphylaxis.
Choice D rationale: Urinary retention is not a typical manifestation of anaphylaxis to penicillin and might not be directly linked to the allergic reaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Nasal cyanocobalamin for pernicious anemia is commonly administered once a week. The instruction to administer the medication into one nostril aligns with the correct technique.
Choice B rationale: Post-administration lying down isn't necessary for this medication.
Choice C rationale: The duration of treatment can vary; a fixed duration isn't universally applicable.
Choice D rationale: Using a nasal decongestant isn't a routine part of administering nasal cyanocobalamin for pernicious anemia.
Correct Answer is B
Explanation
Choice A rationale: Erythromycin lactobionate should be reconstituted with sterile water for injection, not dextrose solution. Dextrose solution can cause precipitation and reduce the effectiveness of the medication.
Choice B rationale: Erythromycin lactobionate is a macrolide antibiotic that can cause ototoxicity, which is damage to the inner ear that can result in hearing loss, tinnitus, or vertigo. The nurse should monitor the client for signs of ototoxicity and report any changes to the provider.
Choice C rationale: Erythromycin lactobionate can cause diarrhea, not constipation. The nurse should advise the client to drink plenty of fluids and monitor for signs of dehydration.
Choice D rationale: Erythromycin lactobionate should be administered over 20 to 60min, depending on the dose and the client's condition. Administering the medication too rapidly can cause phlebitis, thrombophlebitis, or cardiac arrhythmias.
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