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 D
Explanation
A. Food, Drug and Cosmetic Act:
The Food, Drug, and Cosmetic Act (FD&C Act) is a federal law that regulates the manufacturing, labeling, and distribution of food, drugs, cosmetics, and medical devices in the United States. While the FD&C Act does provide some regulatory authority over certain aspects of dietary supplements, such as labeling requirements and good manufacturing practices, it is not the primary law governing the regulation of herbal and dietary supplements.
B. Joint Commission on the Accreditation of Healthcare Organizations:
The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), now known as The Joint Commission, is an independent, nonprofit organization that accredits and certifies healthcare organizations and programs in the United States. However, The Joint Commission is not responsible for regulating herbal and dietary supplements.
C. Health and Human Services (HHS):
The Department of Health and Human Services (HHS) is a cabinet-level executive branch department of the U.S. federal government. While HHS oversees various health-related agencies, including the Food and Drug Administration (FDA), it is not the primary regulatory authority for herbal and dietary supplements.
D. Dietary Supplement Health and Education Act (DSHEA):
The Dietary Supplement Health and Education Act (DSHEA) of 1994 is the primary law that regulates herbal and dietary supplements in the United States. DSHEA defines dietary supplements, sets forth labeling requirements, establishes good manufacturing practices, and outlines the responsibilities of manufacturers and distributors of dietary supplements. Under DSHEA, dietary supplements are regulated as a category of food rather than as drugs.
Correct Answer is B
Explanation
A. Kanamycin (Kantrex):
Kanamycin is an aminoglycoside antibiotic, but it is not commonly used as a first-line treatment for MRSA infections. Aminoglycosides are not typically preferred for treating MRSA because they are not as effective against these resistant bacteria compared to other agents like vancomycin.
B. Vancomycin:
Vancomycin is a glycopeptide antibiotic and is considered the drug of choice for the treatment of MRSA infections, including serious bloodstream infections, pneumonia, and skin and soft tissue infections. It works by inhibiting cell wall synthesis in bacteria, including MRSA.
C. Streptomycin:
Streptomycin is another aminoglycoside antibiotic, similar to kanamycin. Like kanamycin, streptomycin is not typically used as a first-line treatment for MRSA infections because it is less effective against resistant strains compared to other agents like vancomycin.
D. Penicillin:
Penicillin and other beta-lactam antibiotics are ineffective against MRSA because MRSA is resistant to these antibiotics, including methicillin. Therefore, penicillin would not be an appropriate choice for treating MRSA infections.
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