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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
a. Identify the client using two identifiers - While this is an important step for medication safety, it should occur immediately before administering the medication, not necessarily before removing it from the dispensing cabinet.
b. Document the administration of the medication - Documentation is crucial but should occur after the medication has been administered to ensure accurate recording.
c. Remove the medication from the medication dispensing cabinet - This is the first step in the medication administration process as it ensures the correct medication is retrieved from the cabinet and ready for administration.
d. Compare the amount of medication available to the inventory record - While this is an important step for medication reconciliation and ensuring accurate inventory management, it should occur after the medication has been removed from the cabinet and administered to the patient.
Correct Answer is D
Explanation
Choice A rationale: TPN cannot be administered subcutaneously due to its composition.
Choice B rationale: Intraosseous access is for emergency situations when IV access isn't attainable.
Choice C rationale: A midline catheter might not be suitable for the hypertonic nature of TPN and can lead to complications.
Choice D rationale: Total parenteral nutrition (TPN) is a hypertonic solution that requires infusion into a large vein. The central venous access device allows for high-flow rates and avoids irritation or damage to smaller peripheral veins.
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