The nurse notes that the patient is scratching and has hives 2 hours after receiving a dose of antibiotic medication.
The patient soon starts having difficulty breathing and his blood pressure drops. What is the correct analysis of the patient’s condition?
The patient is experiencing a moderate allergic reaction and should improve shortly.
These symptoms are probably due to food poisoning because very few patients have true allergic responses.
The patient is having an anaphylactic reaction and emergency interventions should be started.
The patient is having a mild reaction that can be treated easily with an antihistamine.
The Correct Answer is C
Rationale for Choice A:
Incorrect. While the patient is experiencing an allergic reaction, it is not moderate. The presence of difficulty breathing and a drop in blood pressure are signs of a severe, life-threatening anaphylactic reaction.
Anaphylaxis is a severe, rapid-onset allergic reaction that can lead to death if not treated promptly. It typically involves multiple body systems, including the skin, respiratory system, cardiovascular system, and gastrointestinal system.
Moderate allergic reactions typically present with localized symptoms such as hives, itching, and redness. They do not typically involve respiratory or cardiovascular compromise.
Rationale for Choice B:
Incorrect. The patient's symptoms are not consistent with food poisoning. Food poisoning typically causes gastrointestinal symptoms such as nausea, vomiting, diarrhea, and abdominal cramps. It does not typically cause hives, difficulty breathing, or a drop in blood pressure.
The timing of the symptoms, occurring 2 hours after receiving an antibiotic, strongly suggests an allergic reaction to the medication.
Rationale for Choice C:
Correct. The patient's symptoms are consistent with anaphylaxis, a severe allergic reaction that requires immediate emergency treatment.
Key features of anaphylaxis include:
Skin involvement (hives, itching, flushing, swelling)
Respiratory distress (difficulty breathing, wheezing, tightness in the chest) Cardiovascular compromise (drop in blood pressure, lightheadedness, fainting) Gastrointestinal symptoms (nausea, vomiting, diarrhea)
Swelling of the tongue or throat
Rationale for Choice D:
Incorrect. The patient's reaction is not mild and cannot be treated with an antihistamine alone. Antihistamines are effective for mild allergic reactions, but they are not sufficient to treat anaphylaxis.
Anaphylaxis requires immediate treatment with epinephrine, which is a life-saving medication that can reverse the effects of the allergic reaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Side effect: A side effect is an effect of a drug that is secondary to the main intended effect. It is usually predictable and may be either beneficial or harmful. However, constipation is not a common or expected side effect of iron supplements. It is more likely to be an adverse reaction.
Choice B rationale:
Therapeutic effect: The therapeutic effect is the intended effect of a drug, the one that is desired to treat the condition. In this case, the therapeutic effect of the iron supplement would be to increase the patient's iron levels. Constipation is not the desired effect of the iron supplement, so it is not a therapeutic effect.
Choice C rationale:
Adverse reaction: An adverse reaction is an unwanted or harmful reaction to a drug that is not necessarily predictable. It can range from mild to severe. Constipation is a common adverse reaction to iron supplements. It is thought to be caused by the iron binding to undigested food in the intestines, making it harder to pass stool.
Choice D rationale:
Toxicity: Toxicity refers to a poisonous or harmful effect of a drug. It is usually caused by taking too much of a drug or by a drug interacting with another drug or substance. Constipation is not a sign of iron toxicity. Iron toxicity can cause symptoms such as nausea, vomiting, abdominal pain, and diarrhea.
Correct Answer is A
Explanation
Choice A rationale:
Thick, creamy yellow discharge is a hallmark characteristic of purulent drainage. This type of drainage is commonly referred to as pus and is indicative of an infection within the wound. It is composed of white blood cells, dead bacteria, cellular debris, and inflammatory cells, giving it its characteristic opaque, thick, and yellowish appearance.
Purulent drainage is a significant clinical finding that requires prompt attention and intervention. Early identification and management of wound infections can prevent complications such as abscess formation, cellulitis, sepsis, and delayed wound healing.
Accurate documentation of purulent drainage is essential for communication among healthcare providers, monitoring wound progress, and guiding treatment decisions.
Choice B rationale:
Serosanguineous drainage is a mixture of serous fluid (clear, thin, and watery) and blood. It often appears pink or slightly red and is commonly observed in the early stages of wound healing or after dressing changes. While it may contain a small amount of blood, it lacks the thick, creamy consistency and yellow color that are characteristic of purulent drainage.
Choice C rationale:
Serous drainage is clear, thin, and watery, resembling plasma. It is a normal part of the wound healing process and is often seen in the early inflammatory stage. It does not contain the thick consistency or yellow coloration that are indicative of purulent drainage.
Choice D rationale:
Sanguineous drainage is composed primarily of fresh blood. It is bright red in color and typically indicates active bleeding within the wound. It does not exhibit the thick, creamy consistency or yellow hue that are characteristic of purulent drainage.
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