A nurse is assessing a client who received an IM antibiotic injection 15 min ago. Which of the following findings should the nurse identify as an indication of a possible anaphylactic reaction to the medication?
A feeling of swelling in the feet
Pain at the injection site
A sudden decrease in heart rate
A sharp decrease in blood pressure
The Correct Answer is D
A. A feeling of swelling in the feet:
Swelling in the feet is not a typical sign of an anaphylactic reaction to an IM antibiotic injection. Anaphylaxis usually involves more rapid and widespread symptoms that can affect various body systems.
B. Pain at the injection site:
Pain at the injection site is a common side effect of intramuscular (IM) injections and is not typically indicative of an anaphylactic reaction. Anaphylactic reactions are characterized by more systemic and severe symptoms.
C. A sudden decrease in heart rate:
An anaphylactic reaction typically involves an increase in heart rate rather than a decrease. The body's response to an allergen in an anaphylactic reaction often includes a rapid heart rate, as part of the systemic release of inflammatory mediators.
D. A sharp decrease in blood pressure:
This is the correct answer. Anaphylactic reactions can lead to a sudden and severe drop in blood pressure, which is a critical and life-threatening symptom. This is due to the release of vasodilatory substances and increased permeability of blood vessels, resulting in a decrease in blood volume within the vessels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","F"]
Explanation
Correct responses
A. Lactose intolerant: Lactose intolerance can lead to lower dairy intake, which may reduce calcium intake, increasing the risk of osteoporosis.
B. Alcohol use: Excessive alcohol consumption can interfere with calcium absorption and bone health, increasing the risk of osteoporosis.
C. Smoking history: Smoking is associated with decreased bone density and increased risk of osteoporosis due to its negative effects on bone metabolism.
F. Vitamin D level: The client's vitamin D levels are below the recommended range. Vitamin D is crucial for calcium absorption and bone health, so insufficient levels can increase the risk of osteoporosis.
The other factors are less directly related to osteoporosis risk in this client:
D. Phosphorous level: The phosphorous level is within the normal range and is not directly linked to osteoporosis risk.
E. Activity level: The activity level is not provided in the information; however, physical activity is generally important for bone health. If the client is sedentary, it could be a risk factor, but it's not specified here.
Correct Answer is ["B","C","D"]
Explanation
A. Cholesterol level:
While hyperlipidemia (elevated cholesterol levels) is associated with cardiovascular disease, it is not a direct factor affecting wound healing. Cholesterol levels primarily impact vascular health and are not directly related to the cellular and tissue processes involved in wound repair.
B. Prealbumin level:
Prealbumin is a protein that reflects recent dietary intake and nutritional status. Low prealbumin levels can indicate malnutrition, which is associated with delayed wound healing. Adequate protein intake is crucial for tissue repair and wound healing.
C. History of malnutrition:
Malnutrition is a significant risk factor for delayed wound healing. Adequate nutrition is essential for the body to carry out the processes involved in wound healing, including cell proliferation, collagen synthesis, and immune function.
D. History of diabetes mellitus:
Diabetes mellitus can impair wound healing due to factors such as reduced blood flow, impaired immune response, and neuropathy. Elevated blood sugar levels in diabetes can interfere with the normal healing processes, leading to delayed wound healing.
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