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 C
Explanation
A. Give the adolescent a short story pamphlet about puberty. While educational materials about puberty can be helpful, they do not provide specific information about a pelvic examination.
B. Describe the steps to the adolescent's guardian. The explanation should be directed to the adolescent to ensure they understand and feel comfortable. The guardian may be included if the adolescent prefers.
C. Show an online video that demonstrates what to expect. A visual demonstration can help reduce anxiety by familiarizing the adolescent with the procedure in a clear and informative way.
D. Use an anatomically correct puppet to demonstrate. Puppets are more appropriate for explaining procedures to younger children, not adolescents.
Correct Answer is D
Explanation
A. "Submitting an incident report to risk management following a client fall." While this is important for safety and quality improvement, it is not a direct act of client advocacy.
B. "Documenting the effectiveness of pain medication in the client's health record." This is a critical part of nursing documentation but does not actively advocate for the client.
C. "Asking another nurse to check a medication calculation for a client." This promotes medication safety, but it is not an example of client advocacy.
D. "Informing the family of a deceased client of the client's wish to be an organ donor." Advocacy means ensuring the client’s wishes are honored, especially in sensitive situations like organ donation.
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