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 D, A, B, C
Explanation
Choice A rationale: This is the second step and equalizes the pressure in the vial and makes it easier to draw up the insulin.
Choice B rationale: This is the third step. Regular insulin is clear and should be drawn up first to avoid mixing with NPH insulin, which is cloudy. By drawing up the regular insulin first, the nurse avoids transferring any NPH insulin into the regular insulin vial, which could alter its potency and effectiveness.
Choice C rationale: This is the last step. The total amount of insulin in the syringe should be 16 units (4 units of regular insulin plus 12 units of NPH insulin).
Choice D rationale: This is the first step as it prevents contamination of the NPH insulin with regular insulin.
Correct Answer is A
Explanation
Choice A rationale: Amphotericin B lipid complex can bind to other solutions, leading to precipitation. Priming the tubing with 0.9% sodium chloride ensures that the medication is not wasted due to precipitation in the tubing.
Choice B rationale: The infusion rate and duration depend on the specific guidelines and conditions but are not directly related to priming the tubing.
Choice C rationale: While the administration method might vary, priming the tubing with a compatible solution is more critical for the initial setup.
Choice D rationale: Color change might not be an accurate indicator of medication integrity or effectiveness in this case.
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