A nurse is teaching a client about reducing the risk for osteoporosis. Which of the following statements by the client indicates an understanding of possible anaphylaxis?
A feeling of swelling in the feet
Pain at the injection site
A sudden decrease in heart rate
A sharp decrease in blood pressure
The Correct Answer is D
A. A feeling of swelling in the feet: Swelling in the feet can be caused by various factors such as fluid retention, circulatory issues, or certain medical conditions like venous insufficiency. It is not a typical symptom of anaphylaxis, which usually involves more generalized symptoms such as hives, itching, swelling of the face or throat, difficulty breathing, and a drop in blood pressure.
B. Pain at the injection site: Pain at the injection site is a common side effect of receiving an injection or medication. It occurs due to tissue irritation or trauma from the needle. While allergic reactions can cause localized redness, swelling, or itching at the injection site, severe pain alone is not a hallmark symptom of anaphylaxis.
C. A sudden decrease in heart rate: Anaphylaxis typically leads to an increase in heart rate (tachycardia) rather than a decrease. This increase in heart rate is a response to the body's attempt to compensate for the drop in blood pressure caused by anaphylaxis. Bradycardia (a decrease in heart rate) is not a typical feature of anaphylaxis unless it occurs very late in a severe reaction due to profound circulatory collapse.
D. A sharp decrease in blood pressure: This choice is indicative of an understanding of possible anaphylaxis. Anaphylaxis can cause a rapid and severe drop in blood pressure, known as hypotension. This drop in blood pressure is often a key feature of anaphylaxis and can lead to symptoms such as dizziness, fainting, confusion, and shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Extend the client's neck while securing the ties: This action can compromise the client's airway and is not recommended during tracheostomy tie changes. The client's neck should be in a comfortable, neutral position during the procedure.
B. Use a quick-release knot to secure the ties: Quick-release knots are not typically used for securing tracheostomy ties. Instead, a secure knot that can be easily tied and untied is preferred to ensure the stability of the tracheostomy tube.
C. Allow space for three fingers under the ties when securing.
Allowing space for three fingers is not a standard practice for tracheostomy ties. The ties should be snug but not overly tight, typically allowing for one or two fingers’ width to ensure proper fit and comfort.
D. When changing tracheostomy ties, it is essential to maintain airway security and prevent accidental dislodgement of the tracheostomy tube. The nurse should secure the new ties first before removing the old ones to ensure the tracheostomy remains stable.
Correct Answer is B
Explanation
A. "I will remove my antiembolic stockings while I am in bed": Antiembolic stockings, also known as compression stockings, are worn to prevent deep vein thrombosis (DVT) by promoting venous return. Removing them while in bed would compromise their effectiveness in preventing blood clots.
B. "I will perform ankle and knee exercises every hour."
Performing ankle and knee exercises every hour helps prevent complications such as muscle atrophy, contractures, and thromboembolism associated with immobility. These exercises promote circulation, maintain joint mobility, and prevent stiffness.
C. "I will hold my breath when rising from a sitting position": Holding one's breath while rising from a sitting position can increase intra-abdominal pressure and potentially cause dizziness or fainting. It is not a recommended practice and may lead to orthostatic hypotension.
D. "I will have my partner help me change positions every 4 hours": Changing positions every 4 hours is important for preventing pressure ulcers and promoting comfort, but it may not be frequent enough to prevent other adverse effects of immobility, such as joint stiffness and muscle weakness. Frequent position changes, at least every 2 hours, are recommended to maintain circulation and prevent complications.
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