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 A
Explanation
A. Permanent, inheritable changes to DNA:
Mutations are alterations or changes in the DNA sequence of an organism's genome. These changes can be permanent and heritable, meaning they are passed on to offspring during reproduction. Mutations can occur spontaneously or be induced by various factors such as environmental agents, radiation, or errors in DNA replication or repair mechanisms. These changes can lead to variations in traits among individuals within a population and are essential for the process of evolution.
B. An organism that is capable of causing disease:
This definition refers to the term "pathogen." Pathogens are organisms, such as bacteria, viruses, fungi, or parasites, that are capable of causing disease in their hosts. Pathogens can infect humans, animals, plants, or other organisms and can lead to a wide range of diseases, from mild infections to life-threatening illnesses.
C. The severity of a disease that an organism is able to cause:
This definition refers to the term "virulence." Virulence is a measure of the severity or harmfulness of a pathogen, indicating its ability to cause disease in a host organism. Highly virulent pathogens are more likely to cause severe illness or death, while less virulent pathogens may cause milder symptoms or asymptomatic infections. Virulence factors, such as toxins, adhesion molecules, or evasion mechanisms, contribute to the pathogen's ability to cause disease.
D. A substance that can inhibit the growth of bacteria:
This definition refers to the term "antibiotic." Antibiotics are chemical substances produced by microorganisms, fungi, or synthesized in the laboratory that can inhibit the growth of or kill bacteria. Antibiotics are commonly used to treat bacterial infections and work by targeting specific bacterial structures or metabolic processes, thereby disrupting bacterial growth and survival. However, antibiotics are not mutations; instead, they are therapeutic agents used to combat bacterial infections.
Correct Answer is ["125"]
Explanation
To calculate the rate at which the IV pump should be set to deliver 3,000 mL of intravenous fluids over 24 hours, you would divide the total volume (3,000 mL) by the total time (24 hours):
Rate (mL/hr) = Total volume (mL) / Total time (hours)
Rate = 3,000 mL / 24 hours
Rate ≈ 125 mL/hr
Rounding to the nearest whole number, the IV pump should be set to deliver approximately 125 mL/hr.
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