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 A
Explanation
A. A nurse administers a medication without first identifying the client.
Negligence refers to the failure to provide care that a reasonable and prudent person would normally perform in a similar situation, resulting in harm to the client. In this scenario, administering medication without first identifying the client constitutes negligence because it violates the standard of care expected of a nurse. Proper identification of the client is essential to ensure that the correct medication is administered to the right individual, preventing medication errors and potential harm.
B. A nurse begins a blood transfusion without obtaining consent from a client:
This situation involves a failure to obtain informed consent, which is a violation of the client's rights but does not necessarily constitute negligence. Negligence typically involves a failure to provide proper care rather than a failure to obtain consent.
C. An assistive personnel prevents a client from leaving the facility:
While preventing a client from leaving the facility without appropriate authorization may be inappropriate or a breach of the client's rights, it does not necessarily constitute negligence. Negligence involves a failure to provide care that meets the standard of care expected in a given situation.
D. An assistive personnel discusses client care in the facility cafeteria with visitors present:
This situation may involve a breach of confidentiality or privacy but does not constitute negligence unless the discussion leads to harm or adverse consequences for the client. Negligence typically involves a failure to provide care that results in harm or injury to the client.
Correct Answer is C
Explanation
A.Placing gauze under the flanges of the tracheostomy tube is not recommended because it can create a breeding ground for bacteria and increase the risk of infection.Pre-cut gauze pads should be used to avoid loose fibers from entering the stoma.
B.Full-strength hydrogen peroxide is too harsh and can cause skin irritation or damage. When performing tracheostomy care, the skin around the stoma should be cleaned with a mild saline solution.
C.A collar with hook-and-loop fastenersis commonly used to secure the tracheostomy tube in place. This collar should be snug enough to hold the tube securely but not too tight to cause discomfort or restrict airflow. The collar helps prevent accidental dislodgement of the tracheostomy tube, ensuring it remains properly positioned.
D.Sterile gloves should be worn when cleaning the inner cannula of the tracheostomy tube to minimize the risk of introducing pathogens.
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