A nurse is caring for a client who just received a dose of IV ampicillin. Which of the following client reactions requires priority intervention by the nurse?
BP 98/62
Urticaria
Wheezing
Pulse rate 104/min
The Correct Answer is C
A. BP 98/62:
A blood pressure of 98/62 mmHg is within the normal range for an adult, although it's slightly lower than the average blood pressure. While monitoring blood pressure is important, this reading doesn't indicate a critical condition and doesn't require immediate intervention.
B. Urticaria:
Urticaria, also known as hives, is a skin rash characterized by raised, itchy welts. While it can be uncomfortable and may indicate an allergic reaction, it's not immediately life-threatening. However, it does warrant attention and further assessment.
C. Wheezing:
Wheezing is a high-pitched whistling sound that occurs during breathing and can indicate airway obstruction, such as in an allergic reaction or asthma exacerbation. Wheezing can be a sign of a severe allergic reaction or anaphylaxis, which requires immediate intervention to ensure the patient's airway remains open and to administer appropriate treatment.
D. Pulse rate 104/min:
A pulse rate of 104 beats per minute (bpm) is slightly elevated but within the normal range for an adult. While it's important to monitor heart rate, this finding alone doesn't indicate an immediate threat to the patient's life.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The herbal product must contain only one active ingredient:
This statement is not a legal requirement contained in DSHEA. Many dietary supplements contain multiple active ingredients, such as vitamins, minerals, herbs, amino acids, and other substances. DSHEA does not mandate that dietary supplements contain only one active ingredient.
B. Effectiveness must be demonstrated by the manufacturer:
DSHEA does not require manufacturers to demonstrate the effectiveness of dietary supplements before marketing. Unlike pharmaceutical drugs, which must undergo premarket approval by the Food and Drug Administration (FDA) to demonstrate safety and efficacy, dietary supplements do not need to prove effectiveness to be marketed. Instead, manufacturers are responsible for ensuring the safety of their products and making truthful claims on product labels.
C. Dietary supplements must state that the product is not intended to diagnose, treat, cure, or prevent any disease:
This statement accurately reflects a legal requirement contained in DSHEA. Under DSHEA, dietary supplement labels must include a disclaimer stating that the product is not intended to diagnose, treat, cure, or prevent any disease. This disclaimer helps to clarify that dietary supplements are intended to support general health and well-being rather than to treat specific diseases or medical conditions.
D. Dietary supplements must be tested for safety prior to marketing:
While DSHEA requires manufacturers to ensure the safety of their dietary supplements, it does not mandate standardized premarket testing for safety by regulatory authorities. Instead, manufacturers are responsible for conducting safety assessments and ensuring that their products are safe for consumers. The FDA may take action against manufacturers if a product is found to be unsafe or if it violates regulatory requirements, but premarket testing is not a specific legal requirement under DSHEA.
Correct Answer is C
Explanation
A. Echinacea:
Echinacea is commonly used to support the immune system and may be used to prevent or reduce the severity of colds and other infections. However, it is not typically used specifically for treating menopause-related hot flashes.
B. Saw palmetto:
Saw palmetto is primarily used for managing symptoms related to the prostate gland, such as benign prostatic hyperplasia (BPH), and is not commonly used for treating menopause-related hot flashes in women.
C. Black cohosh:
Black cohosh is one of the most widely studied herbal remedies for managing menopause-related symptoms, including hot flashes. Research suggests that black cohosh may help reduce the frequency and severity of hot flashes in some women experiencing menopausal symptoms.
D. Cranberry juice:
Cranberry juice is often used to promote urinary tract health and prevent urinary tract infections (UTIs). While it may have some health benefits, cranberry juice is not typically used for managing menopause-related hot flashes.
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