A nurse is collecting data from a client following a bee sting. Which of the following findings can indicate an anaphylactic reaction to the venom?

Nausea and vomiting

Generalized edema

Bradycardia

Urticaria

Answer and Explanation

The Correct Answer is B

A.   Common allergic reactions but not specific to anaphylaxis.
B.   Can be a sign of anaphylaxis, reflecting a systemic allergic response.
C.   Anaphylaxis is more commonly associated with tachycardia.
D.   Hives are a common allergic reaction and can occur in anaphylaxis, but they are not specific to it.

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Correct Answer is A

Explanation

A. Elevating the head of the client's bed to 45° during meals helps prevent aspiration by promoting proper swallowing and reducing the risk of food or liquids entering the airway.
B. Instructing the client to tilt their head back while swallowing is not recommended, as it may increase the risk of aspiration.
C. Turning on the television during meals is unrelated to reducing the risk of aspiration pneumonia.
D. Providing the client with oral hygiene is important for overall health but does not specifically address the risk of aspiration pneumonia.

A. Instruct client to use an incentive spirometer every 4 hr. B. Place the client in a room with negative-pressure airflow. C. Serve cooked fruit with meals. D. Report temperatures greater than 39.5 C (102.3 F lasting more than 4 hr.)

Correct Answer is D

Explanation

A. The use of an incentive spirometer is more relevant for preventing respiratory complications, not related to the client's low WBC count.
B. Negative-pressure airflow rooms are typically used for clients with airborne infections, not those with low WBC counts.
C. Cooked fruits may be advisable to reduce the risk of bacterial contamination in immunosuppressed clients, but it does not directly address the low WBC count.
D. Reporting temperatures greater than 39.5°C (102.3°F) lasting more than 4 hours is crucial as it may indicate an infection, and prompt intervention is needed in immunosuppressed clients.

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A nurse is collecting data from a client following a bee sting. Which of the following findings can indicate an anaphylactic reaction to the venom?

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