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 B
Explanation
A. Decision to administer either a bactericidal or bacteriostatic drug:
Culture and sensitivity tests provide information about the susceptibility of the microorganism to specific antimicrobial agents. Based on this information, healthcare providers can choose between bactericidal (agents that kill bacteria) or bacteriostatic (agents that inhibit bacterial growth) drugs. For example, if the culture indicates that the microorganism is susceptible to a bactericidal drug, such as penicillin, the healthcare provider may choose to administer that type of drug.
B. Microbial susceptibility to an anti-infective:
This option accurately describes one of the primary purposes of culture and sensitivity tests. These tests determine whether the microorganism causing the infection is susceptible or resistant to specific antimicrobial agents. This information guides the selection of the most appropriate anti-infective therapy to effectively treat the infection.
C. Duration of the antibacterial drug therapy:
While culture and sensitivity tests provide valuable information about microbial susceptibility to antimicrobial agents, they do not specifically determine the duration of antibacterial drug therapy. The duration of therapy is often determined based on factors such as the type and severity of the infection, the patient's response to treatment, and clinical guidelines, rather than solely on the results of culture and sensitivity tests.
D. Decision to administer empiric therapy:
Empiric therapy involves the initiation of antimicrobial treatment based on clinical judgment and knowledge of likely pathogens before culture and sensitivity results are available. Culture and sensitivity tests help confirm the causative microorganism and guide subsequent treatment decisions, including adjustments to therapy based on the results. Therefore, while culture and sensitivity tests inform decisions regarding antimicrobial therapy, they do not directly determine whether empiric therapy should be initiated.
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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