During antibiotic therapy, the nurse will monitor closely for signs and symptoms of a hypersensitivity reaction. Which of these assessment findings may be an indication of a hypersensitivity reaction? (Select all that apply.)

Shortness of breath

Black hairy tongue

Itching

Swelling of the tongue

Wheezing

Answer and Explanation

Correct Answer : A,C,D,E

Choice A rationale:

Shortness of breath is a common symptom of a hypersensitivity reaction. This occurs because the body’s immune system responds to a foreign substance, known as an antigen, by producing specific antibodies. This immune response can cause inflammation and swelling in various parts of the body, including the airways, leading to shortness of breath.

Choice B rationale:

A black hairy tongue is not typically associated with a hypersensitivity reaction. It is a condition that causes the tongue to appear black and hairy, and it’s usually caused by an overgrowth of bacteria or yeast on the tongue. It’s not related to allergies or hypersensitivity reactions.

Choice C rationale:

Itching is another common symptom of a hypersensitivity reaction. When the body encounters an antigen, it triggers an immune response that releases chemicals like histamine. Histamine can cause itching, among other symptoms.

Choice D rationale:

Swelling of the tongue can be a symptom of a severe hypersensitivity reaction known as anaphylaxis. This is a medical emergency that requires immediate attention. The swelling is caused by inflammation in response to an antigen.

Choice E rationale:

Wheezing is a symptom of a hypersensitivity reaction, specifically type I hypersensitivity. This type of reaction includes allergic disorders, which affect the lungs among other parts of the body. The immune response to an antigen can cause the airways to narrow and produce a wheezing sound.

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Correct Answer is ["A","C","D"]

Explanation

Choice A rationale:

A WBC count of 16,000/mm is higher than the normal range of 5,000 to 10,000 cells/mm. This indicates that the body is fighting an infection, which is a common reason for prescribing Vancomycin. Therefore, a high WBC count could indicate a therapeutic response to the medication as it suggests that the body’s immune system is actively fighting the infection.

Choice B rationale:

A BUN level of 42 mg/dl is higher than the normal range of 7 to 20 mg/dL3456. Elevated BUN levels can indicate kidney damage or disease, which is not a desired therapeutic response to Vancomycin. Vancomycin can be nephrotoxic, and its use requires careful monitoring of kidney function. Therefore, a high BUN level does not indicate a therapeutic response to the medication. Choice C rationale:

A blood pressure reading of 95/64 is considered normal. Maintaining normal blood pressure is important for overall health and can indicate that the patient’s body is responding well to the medication. Therefore, a blood pressure reading within the normal range could indicate a therapeutic response to Vancomycin.

Choice D rationale:

A body temperature of 101.8F is considered a fever14. Fever is a common response to infection and can indicate that the body is fighting off an infection, which is a common reason for prescribing Vancomycin. Therefore, a high body temperature could indicate a therapeutic response to the medication as it suggests that the body’s immune system is actively fighting the infection.

A. Bounding peripheral pulses B. Moist mucous membranes C. Bradycardia D. Decreased urine specific gravity

Correct Answer is D

Explanation

Choice A rationale:

Bounding peripheral pulses are not typically associated with diabetes insipidus. Diabetes insipidus is a condition characterized by excessive thirst and excretion of large amounts of severely dilute urine.

Choice B rationale:

Moist mucous membranes are not a common finding in diabetes insipidus. In fact, due to excessive urination, patients may experience dehydration which can lead to dry mucous membranes.

Choice C rationale:

Bradycardia, or a slower than normal heart rate, is not a typical symptom of diabetes insipidus. The condition does not directly affect the heart rate.

Choice D rationale:

Decreased urine specific gravity is a key finding in diabetes insipidus. The condition causes an imbalance of water in the body, leading to the production of large amounts of dilute (or low specific gravity) urine.

Please note that these rationales are based on general knowledge about diabetes insipidus and the specific symptoms mentioned in the choices. For a more detailed understanding, it’s recommended to refer to medical textbooks or consult with healthcare professionals.

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During antibiotic therapy, the nurse will monitor closely for signs and symptoms of a hypersensitivity reaction. Which of these assessment findings may be an indication of a hypersensitivity reaction? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Examine the following patient data for a patient who has been prescribed vancomycin. The nurse is evaluating a patient after administering several doses of Vancomycin IV. Which of the following changes would indicate a therapeutic response to the medication? (Select all that apply)

Correct Answer is ["A","C","D"]

Explanation

A nurse is caring for a client who has diabetes insipidus. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

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