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 ["50"]
Explanation
To calculate the infusion rate in gtt/min, the nurse needs to use the formula:
Infusion rate (gtt/min) = Volume (mL) x Drop factor (gtt/mL) / Time (min)
Plugging in the given values, we get:
Infusion rate (gtt/min) = 400 mL x 60 gtt/mL / 480 min
Simplifying, we get:
Infusion rate (gtt/min) = 50 gtt/min
Therefore, the nurse should set the manual IV infusion to deliver 50 gtt/min.
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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