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","B","C"]
Explanation
A. Positive Trousseau's sign: A positive Trousseau’s sign (carpal spasm induced by inflating a blood pressure cuff) is a classic indicator of hypocalcemia due to increased neuromuscular excitability.
B. Muscle cramps: Hypocalcemia leads to increased nerve excitability, causing muscle cramps, spasms, and tetany.
C. Tingling sensation around the lips: This is a common early sign of hypocalcemia, known as perioral paresthesia, due to increased nerve excitability.
D. Negative Chvostek's sign: A client with hypocalcemia would have a positive Chvostek’s sign, which is facial twitching when the facial nerve is tapped.
E. Abdominal distention: Hypocalcemia is more associated with diarrhea and hyperactive bowel sounds, not abdominal distention, which is more typical of hypokalemia.
Correct Answer is A
Explanation
A. "Use IV tube ports when injecting medications." Latex-free IV ports should be used instead of rubber stoppers found in some IV bags and vials.
B. "Remove medication from multi-dose vials with the stopper in place." Many vial stoppers contain latex, so the nurse should use single-dose vials or vials labeled as latex-free.
C. "Secure loose cords in stockinette with tape." Stockinettes are sometimes made with latex, posing a risk to the client. Non-latex materials should be used instead.
D. "Schedule the client's surgery as the last procedure of the day." Clients with latex allergies should be scheduled first to minimize exposure to airborne latex particles from gloves and equipment used earlier in the day.
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