A nurse is caring for a client.
Select the 4 findings that require immediate follow-up.
Heart rate
Blood pressure
Breath sounds
Urticaria
Temperature
Swollen tongue
Correct Answer : A,B,C,F
A. Heart rate: The client's heart rate increased significantly from 66/min to 104/min within 30 minutes of antibiotic administration. This tachycardia, especially in the context of other alarming symptoms, can indicate a compensatory mechanism for hypoperfusion due to vasodilation, a common feature of anaphylaxis.
B. Blood pressure: The client’s blood pressure has dropped significantly from 108/56 mm Hg to 88/56 mm Hg. Hypotension could be a sign of anaphylactic shock, especially considering the allergic symptoms (urticaria, swelling of the tongue).
C. Breath sounds: The presence of wheezing along with a drop in oxygen saturation (pulse oximetry 93%) is concerning for bronchospasm, which is common in allergic reactions or anaphylaxis. The client may need immediate airway management, including bronchodilators.
D. Urticaria: While urticaria (hives) is a classic sign of an allergic reaction, it is a skin manifestation and not as immediately life-threatening as airway compromise, hypotension, or a compensatory tachycardia.
E. Temperature: The temperature remains within a mild range (37.5°C/99.5°F to 37.6°C/99.7°F). It is slightly elevated but not concerning in the context of an allergic reaction. The temperature should be monitored but does not require immediate follow-up compared to the more critical findings.
F. Swollen tongue: Swelling of the tongue is a serious symptom of an allergic reaction and can lead to airway obstruction. Immediate intervention is required to prevent further complications, such as anaphylaxis, which can be life-threatening.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Advance the needle 6 mm (7 in) below the skin's surface: Intradermal injections should be administered just beneath the skin, not deeply. The needle should be inserted at an angle to form a small bleb just below the epidermis. This depth ensures proper absorption.
B. Point the bevel of the needle upward prior to insertion: The bevel should be facing upward when performing an intradermal injection to ensure the medication is injected just below the skin surface. This positioning helps form a visible wheal or bleb, which is necessary for the tuberculin test.
C. Administer the injection on the dorsal forearm: The recommended site for an intradermal tuberculin test is the inner aspect of the forearm, not the dorsal forearm. The inner forearm provides a flatter surface for easy visualization of the wheal.
D. Insert the needle at a 20° angle to the client's skin: An intradermal injection should be administered at a 5-15° angle to ensure the needle is positioned just beneath the skin’s surface. A 20° angle may result in the injection being too deep.
Correct Answer is ["A","B","C","E"]
Explanation
Rationale:
- Client rates pain as 8 on a scale of 0 to 10 in their left knee. Client reports no relief with pain medications. The client’s pain has worsened from 4/10 despite pain medication, indicating the current pain management approach is ineffective, and the wound may not be healing as expected.
- Mild purulent drainage noted: The presence of purulent drainage is a sign of infection, further indicating that the wound vac therapy has not been successful in preventing or managing infection at the wound site.
- Left knee wound is 3 cm by 2 cm with 1 cm depth, compared to 2 cm by 2 cm with 1 cm depth one week ago: The increase in wound sizefrom 2cm by 2 cm to 3 cm by 2 cm suggests that the wound vac therapy is not promoting healing effectively, leading to a failure of wound closure.
Rationale for Incorrect Choices:
- Wound bed vascular with some approximation of the edges: The wound bed being vascular with some approximation of the edges indicates that there is some healthy tissue and the edges of the wound are coming together. This suggests that some healing is occurring, although it may be slower than expected.
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