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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["50 "]
Explanation
The question is about calculating the volume of phenytoin oral solution that the nurse should administer per dose. The client is prescribed 250 mg of phenytoin and the available solution has a concentration of 25 mg/5 mL.
Let’s calculate the volume step by step:
Step 1: Identify the prescribed dose and the concentration of the available medication. The prescribed dose is 250 mg and the concentration of the available medication is 25 mg/5 mL.
Step 2: Set up the calculation. We want to find out how many mL correspond to the prescribed dose. We can set up the calculation as follows: (Prescribed dose ÷ Concentration) × Volume.
Step 3: Substitute the known values into the calculation. This gives us: (250 mg ÷ 25 mg/5 mL).
Step 4: Perform the division operation first due to the order of operations (BIDMAS/BODMAS). This gives us: (250 mg ÷ 5 mg/mL).
Step 5: Perform the final calculation. This gives us: 50 mL.
So, the nurse should administer 50 mL of the phenytoin oral solution per dose.
Please note that this calculation assumes that the prescribed dose (250 mg) is to be administered in one go. If the dose is to be split over the day, the volume to be administered would change accordingly.
Correct Answer is D
Explanation
Choice A rationale:
Rifampin is an antibiotic used to treat or prevent tuberculosis (TB). However, the treatment with this medication typically lasts longer than one month. In fact, TB treatment usually involves taking several drugs for a long time.
Choice B rationale:
While it’s important to take some medications with meals to increase absorption or decrease stomach upset, rifampin should be taken at least 1 hour before or 2 hours after a meal. This helps to ensure optimal absorption of the medication.
Choice C rationale:
Insomnia is not typically listed as a common side effect of rifampin. The medication can cause a number of side effects, but these more commonly include things like upset stomach, loss of appetite, nausea, vomiting, diarrhea, and changes in behavior.
Choice D rationale:
One of the known side effects of rifampin is that it can cause a red-orange discoloration of body fluids, including urine, sweat, saliva, and tears. This can be alarming to patients if they are not forewarned, so it’s important for the nurse to provide this information during discharge instructions.
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