A nurse is assisting with the care of a client who is receiving penicillin via intermittent IV bolus. Which of the following should the nurse recognize as a clinical manifestation of anaphylaxis?
Pallor
Peripheral edema
Hypertension
Pruritus
The Correct Answer is D
Choice A: This is incorrect because pallor is not a sign of anaphylaxis. Pallor can indicate shock, anemia, or hypoxia.
Choice B: This is incorrect because peripheral edema is not a sign of anaphylaxis. Peripheral edema can indicate heart failure, kidney disease, or venous insufficiency.
Choice C: This is incorrect because hypertension is not a sign of anaphylaxis. Hypertension can indicate stress, pain, or renal disease.
Choice D: This is correct because pruritus is a sign of anaphylaxis. Pruritus is a severe itching sensation that can accompany hives, rash, or angioedema.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: BUN or blood urea nitrogen 30 mg/dL is above the normal range of 10 to 20 mg/dL and indicates renal impairment or dehydration, which can be caused by contrast dye used during coronary angiography or blood loss during or after the procedure. The nurse should report this value to the provider and monitor the client for signs of acute kidney injury, such as oliguria, edema, or electrolyte imbalances.
Choice B reason: Sinus rhythm 95/min on a cardiac monitor is within the normal range of 60 to 100/min and does not indicate any cardiac arrhythmia or ischemia.
Choice C reason: Respiratory rate 12/min is within the normal range of 12 to 20/min and does not indicate any respiratory distress or hypoxia.
Choice D reason: PTT or partial thromboplastin time 25 seconds is within the normal range of 25 to 35 seconds and does not indicate any bleeding disorder or anticoagulant therapy.
Correct Answer is B
Explanation
Choice A: This is incorrect because feeling bloated after the procedure is not a reason to call the doctor. Feeling bloated after a colonoscopy is normal due to air being introduced into the colon during the procedure. The client can relieve bloating by passing gas or walking.
Choice B: This is correct because making arrangements for a ride home indicates an understanding of the procedure. The client will receive sedation during a colonoscopy, which can impair their judgment and coordination. The client should not drive or operate machinery until fully recovered from sedation.
Choice C: This is incorrect because eating a light breakfast the morning of the procedure indicates a lack of understanding of the procedure. The client should have nothing by mouth after midnight before a colonoscopy, unless instructed otherwise by the provider. The client should follow a clear liquid diet and take bowel preparation agents as prescribed before the procedure.
Choice D: This is incorrect because having a sore throat from the breathing tube indicates a lack of understanding of the procedure. The client will not have a breathing tube during a colonoscopy, as it does not involve intubation or ventilation. The client may have a mouth guard or bite block to protect their teeth and prevent biting on the endoscope.
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