The nurse administers a medication to the patient.
Which symptoms indicate that the patient is having an allergic reaction rather than a side effect?
The patient correctly demonstrates the exercises and how to use the spirometer.
The patient explains to the nurse why the exercises and spirometer are important.
The patient will correctly demonstrate how to use pursed-lip breathing.
The patient’s pulse oximetry will stay greater than 94% with at least 12 breaths/minute.
The Correct Answer is A
The correct answer is E(None of the Above)
Rationale for E:
The options A, B, C, and D all describe actions or physiological measurements that do not directly indicate an allergic reaction.
Allergic reactions involve the immune system's response to a specific substance, whereas side effects are unintended reactions to a medication that are not caused by an immune response.
Key differences between allergic reactions and side effects:
Allergic reactions:
Typically occur rapidly after exposure to the allergen.
Can involve various body systems, including the skin (hives, itching, rash), respiratory system (wheezing, difficulty breathing, throat tightness), gastrointestinal system (nausea, vomiting, diarrhea), and cardiovascular system (low blood pressure, shock).
May be life-threatening in severe cases, such as anaphylaxis. Side effects:
Can occur at any time during medication use.
Usually more predictable and less severe than allergic reactions.
Often subside as the body adjusts to the medication or with dose adjustments. Important considerations for nurses:
Carefully assess patients for potential allergies before administering medications.
Monitor patients closely for any signs of allergic reactions or side effects after medication administration.
Promptly intervene if an allergic reaction is suspected, following established protocols and administering emergency medications as needed.
Document all observations and actions related to medication administration and patient responses.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale:
Tetanus is an acute infectious disease caused by spores of the bacterium Clostridium tetani.The spores are found everywhere in the environment, particularly in soil, ash, intestinal tracts/feces of animals and humans, and on the surfaces of skin and rusty tools like nails, needles, barbed wire, etc.Anyone can get tetanus, but the disease is particularly common and serious in newborn babies and pregnant women who have not been sufficiently immunized with tetanus-toxoid-containing vaccines.
To ensure that there is adequate antitoxin to neutralize tetanus toxin in the case of a tetanus-prone injury, a booster dose is advised if it has been longer than 10 years since the last tetanus vaccine dose.This is because a single dose of tetanus toxoid produces a rapid anamnestic response. Therefore, if a patient with a puncture wound has not received a tetanus toxoid vaccination in the last 10 years, they would require an additional injection before being discharged from the emergency department.
Choice B rationale:
While it might seem prudent to administer a tetanus toxoid vaccination every year, this is not necessary according to current medical guidelines.Over-vaccination could potentially lead to an increased risk of adverse reactions without providing additional benefits. Therefore, a tetanus toxoid vaccination is not required every year.
Choice C rationale:
A 5-year interval for tetanus toxoid vaccination is not the standard recommendation for general population.However, in some specific cases, such as when indicated for wound management, a tetanus toxoid–containing vaccine might be administered if ≥5 years have elapsed since the previous receipt of any tetanus toxoid–containing vaccine.
Choice D rationale:
A 2-year interval for tetanus toxoid vaccination is not the standard recommendation.The tetanus toxoid vaccination provides protection for a much longer period, and therefore, it is not necessary to administer the vaccine every 2 years.
Correct Answer is C
Explanation
Choice A rationale:
Inaccurate statement: While herbal supplements are derived from plant materials, this does not inherently guarantee their safety or non-toxicity. Some plants contain potent compounds that can have adverse effects, even in small doses.
Lack of regulation: Herbal supplements are not regulated by the FDA in the same way as prescription medications. This means that there is no guarantee of their purity, potency, or consistency.
Potential for interactions: Herbal supplements can interact with prescription medications, potentially leading to harmful side effects.
Choice B rationale:
Cost-related issue: The cost of herbal supplements can vary widely. While some may be less expensive than prescription medications, others can be quite costly.
Misleading focus: Emphasizing cost as a primary factor could lead patients to prioritize affordability over safety and effectiveness.
Choice C rationale:
Addresses quality concerns: This response directly addresses the lack of stringent quality standards for herbal supplements, highlighting a significant safety concern.
Encourages informed decision-making: This response encourages patients to carefully consider the potential risks and benefits of herbal supplements, prompting them to seek reliable information and discuss their choices with healthcare providers.
Choice D rationale:
Convenience vs. safety: While the convenience of herbal supplements may be appealing, this response does not address the potential safety concerns associated with their use.
Potential for misuse: Highlighting convenience could lead to patients using herbal supplements inappropriately or without necessary guidance from healthcare professionals.
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