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

Answer and Explanation

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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Correct Answer is D

Explanation

Choice A rationale: The wrist might not be the optimal site for IV catheter placement following a mastectomy due to potential limitations in venous access and increased risk of complications.
Choice B rationale: The most proximal site is not a specific location and may vary depending on the client's condition and anatomy.
Choice C rationale: The nurse should also avoid placing a catheter in a cordlike vein because they are more prone to infiltration, phlebitis, and nerve damage.
Choice D rationale: The left arm is the safest site to avoid complications such as lymphedema, infection, or thrombosis.

A. WBC 11,000/mm3 B. Creatinine 1.8 mg/dL C. Potassium 4.5 mEq/L D. Fasting blood glucose 130 mg/Dl

Correct Answer is B

Explanation

Choice A rationale: An elevated white blood cell count might indicate an infection but does not directly relate to gentamicin administration.
Choice B rationale: Gentamicin is nephrotoxic, and an increase in creatinine levels could indicate kidney damage or impaired renal function, requiring immediate attention to prevent further nephrotoxic effects.
Choice C rationale: A potassium level within the normal range does not require immediate attention related to gentamicin use.
Choice D rationale: An elevated fasting blood glucose might indicate hyperglycemia but is not directly related to gentamicin administration.

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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

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Correct Answer is D

Explanation

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