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 C
Explanation
Choice A: This is incorrect. The Sims' position is not used for a colposcopy, which is a procedure that examines the cervix with a magnifying device. The client should be placed in the lithotomy position, which involves lying on the back with the legs spread and supported by stirrups.
Choice B: This is incorrect. The nurse should not insert a tampon following the procedure, as this can introduce bacteria and cause infection. The nurse should advise the client to use sanitary pads instead.
Choice C: This is correct. The nurse should instruct the client to avoid sexual intercourse until the cervix is healed, which can take up to a week. Sexual intercourse can cause bleeding, pain, and infection.
Choice D: This is incorrect. The nurse should not reinforce teaching that the procedure involves dilation of the cervix, as this is not true. A colposcopy does not require dilation of the cervix, unlike some other procedures such as endometrial biopsy or hysteroscopy.
Correct Answer is C
Explanation
Choice a is not correct because providing an alcohol-based mouthwash is an action that the nurse should avoid when caring for a client who has stomatitis. Alcohol can dry and irritate the oral mucosa and worsen the condition.
Choice b is not correct because minimizing the use of gravies and sauces is not an action that the nurse should take to help manage stomatitis. Gravies and sauces can help moisten dry foods and make them easier to swallow for a client who has stomatitis.
Choice d is not correct because discouraging drinking with a straw is not an action that the nurse should take to help manage stomatitis. Drinking with a straw can help prevent contact between fluids and sore areas of the mouth and reduce pain for a client who has stomatitis.
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