Which assessment information is most important for the nurse to obtain when evaluating whether treatment of a patient with anaphylactic reaction has been effective?

Blood Pressure

Oxygen Saturation.

Heart Rate.

Orientation.

Answer and Explanation

The Correct Answer is A

Anaphylaxis is a severe and potentially life-threatening allergic reaction that can lead to a rapid drop in blood pressure, known as hypotension. This drop in blood pressure is a critical indicator of the severity of the reaction and the effectiveness of the treatment provided. The nurse needs to monitor the patient's blood pressure closely to ensure it stabilizes and returns to a safe range.

While oxygen saturation, heart rate, and orientation are also important parameters to assess, they are secondary to blood pressure in evaluating the effectiveness of treatment for anaphylaxis. Oxygen saturation can help determine the adequacy of oxygenation, heart rate can indicate the presence of tachycardia (which may be a sign of an ongoing reaction or hypoperfusion), and orientation can provide information about the patient's mental status and potential complications.

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Correct Answer is D

Explanation

The nurse should inform the client that a common side effect of Lisinopril, an ACE inhibitor, is a chronic dry cough. ACE inhibitors can cause irritation in the respiratory tract, leading to a persistent cough. It is important for the client to be aware of this side effect and report it to their healthcare provider if it becomes bothersome.

A. There are crackles throughout both lung fields. B. The patient's radial pulse is 105 beats/min. C. There is sediment and blood in the patient's urine D. The blood pressure increases from 66/50 to 122/74 mm

Correct Answer is A

Explanation

A 3% saline solution is a hypertonic solution used to increase serum sodium levels in cases of severe hyponatremia. However, it can lead to fluid overload and pulmonary edema. The presence of crackles throughout both lung fields indicates the accumulation of fluid in the lungs, which is a serious adverse outcome.

The patient's radial pulse rate of 105 beats/min is within a normal range and does not directly indicate an adverse effect of the saline infusion.

The presence of sediment and blood in the patient's urine may be unrelated to the 3% saline infusion and could indicate other issues such as urinary tract infection or kidney injury.

An increase in blood pressure from 66/50 to 122/74 mmHg is an expected effect of a hypertonic solution like 3% saline, as it can cause an increase in intravascular volume. While the increase in blood pressure is significant, it does not represent an adverse outcome specific to the infusion itself.

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Which assessment information is most important for the nurse to obtain when evaluating whether treatment of a patient with anaphylactic reaction has been effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing education to a client who is prescribed Lisinopril (ACE inhibitor) for hypertension. The nurse will be sure to include what information about a common side effect?

Correct Answer is D

Explanation

A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data represents an adverse outcome (side effect) of this infusion?

Correct Answer is A

Explanation

A client's Sodium level is 128 meq/L. The nurse knows that a likely cause of this lab finding is:

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