A nurse is caring for a client who is receiving a first dose of amoxicillin. Which of the following findings should the nurse report to the provider immediately?
High-pitched wheezing
Urticaria over the entire body
Pruritis of the face
Rhinitis with clear discharge
The Correct Answer is A
A. High-pitched wheezing Wheezing indicates airway constriction, which is a sign of anaphylaxis, a life-threatening allergic reaction. This requires immediate intervention (e.g., stopping the medication, administering epinephrine, and providing oxygen).
B. Urticaria over the entire body While urticaria (hives) is a sign of an allergic reaction, it is not as urgent as airway compromise. It should still be reported but does not take immediate priority over wheezing.
C. Pruritis of the face Facial itching is a mild allergic reaction but does not indicate imminent airway compromise like wheezing does.
D. Rhinitis with clear discharge Nasal congestion or a runny nose can be a mild allergic reaction but is not an emergency.
Priority action: Apply the ABC (Airway, Breathing, Circulation) framework, which prioritizes airway compromise (wheezing) over skin-related allergic reactions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "I will hold my cane on my stronger side." The cane should be held on the stronger (unaffected) side to provide better support and stability while allowing the weaker leg to move more freely.
B. "I should hold my cane 12 inches from my side." The cane should be positioned about 6–10 inches to the side of the foot to ensure proper balance and support.
C. "I will keep my elbow flexed at a 90-degree angle while moving my cane." The elbow should be flexed at about 15–30 degrees, not 90 degrees, to maintain comfort and proper control of the cane.
D. "I should move my weaker leg before moving my cane." The correct sequence is to move the cane first, then move the weaker leg forward, followed by the stronger leg, which provides better stability and reduces fall risk.
Correct Answer is D
Explanation
A. "A narrow base of support is recommended for effective lifting." A wide base of support provides more stability and balance, reducing the risk of injury.
B. "Make sure to bend at the waist when lifting objects more than 30 pounds." Bending at the knees, not the waist, helps maintain a neutral spine and prevents back strain.
C. "Use a twisting motion when moving objects to prevent back strain." Twisting while lifting can cause spinal injuries; instead, move the entire body by pivoting the feet.
D. "Stand close to a heavy object before attempting to lift it." Standing close to the object reduces strain on the back and improves control during lifting.
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