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A nurse is assessing a client who is experiencing an anaphylactic reaction to an antibiotic. Which of the following manifestations of anaphylaxis should the nurse expect?
- A. Hypertonic reflexes
- B. Increase in systolic blood pressure
- C. Angioedema
- D. Urinary retention
Correct Answer: C
Rationale: The correct answer is C: Angioedema. Anaphylaxis is a severe allergic reaction that can cause swelling of the deep layers of the skin, including the subcutaneous tissue and mucosa. Angioedema is a common manifestation of anaphylaxis, typically involving swelling of the lips, face, and throat, which can lead to airway obstruction.
A: Hypertonic reflexes - This is not a typical manifestation of an anaphylactic reaction. Anaphylaxis is more commonly associated with hypotension.
B: Increase in systolic blood pressure - Anaphylaxis typically causes a rapid decrease in blood pressure, leading to hypotension rather than hypertension.
D: Urinary retention - This is not a common manifestation of an anaphylactic reaction. Anaphylaxis is more likely to cause symptoms such as urticaria, bronchospasm, and gastrointestinal symptoms.
Therefore, the correct answer is C, as angioed
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A nurse is caring for a client who is receiving heparin by continuous IV infusion for treatment of venous thrombosis. Which of the following laboratory values should the nurse monitor for in order to titrate the heparin dose?
- A. Platelet function assay
- B. aPTT
- C. INR
- D. Amylase
Correct Answer: B
Rationale: The correct answer is B: aPTT. Activated Partial Thromboplastin Time (aPTT) is a lab value used to monitor heparin therapy. Heparin works by inhibiting clot formation, so monitoring aPTT ensures the blood is at the appropriate level of anticoagulation. If aPTT is too low, there is a risk of clot formation, and if it is too high, there is a risk of bleeding. Platelet function assay (A) measures platelet function, not heparin effectiveness. INR (C) is used to monitor warfarin therapy, not heparin. Amylase (D) is a pancreatic enzyme, not relevant to heparin monitoring. Monitoring aPTT helps maintain the therapeutic range for heparin dosing.
A nurse is reviewing the medication list of a client who has a new prescription for clopidogrel after undergoing coronary artery stenting. Which of the following findings should the nurse report to the provider?
- A. The client is taking acetaminophen
- B. The client is taking valerian
- C. The client is taking vitamin B6
- D. The client is taking ginkgo biloba
Correct Answer: D
Rationale: The correct answer is D: The client is taking ginkgo biloba. Ginkgo biloba is an herbal supplement that can increase the risk of bleeding when taken with clopidogrel, a blood thinner commonly prescribed after coronary artery stenting. The nurse should report this finding to the provider to prevent potential interactions and adverse effects.
A: Acetaminophen is a common pain reliever that does not significantly interact with clopidogrel.
B: Valerian is an herb used for sleep and anxiety, but it does not have a significant interaction with clopidogrel.
C: Vitamin B6 is a water-soluble vitamin that is generally safe to take with clopidogrel and does not pose a significant risk of interaction.
A nurse who is caring for a preschooler should question a prescription for which of the following antibiotics?
- A. Azithromycin
- B. Tetracycline
- C. Cefuroxime
- D. Gentamicin
Correct Answer: B
Rationale: The correct answer is B: Tetracycline. Tetracycline is contraindicated in preschoolers due to its potential to cause permanent discoloration of teeth and inhibition of bone growth. Azithromycin (A) and Cefuroxime (C) are safe choices for preschoolers. Gentamicin (D) is generally used in newborns, not preschoolers.
A nurse is assessing a neonate who was exposed to heroin in utero. Which of the following findings should the nurse identify as an indication that the neonate is experiencing neonatal abstinence syndrome?
- A. Hyporeflexia
- B. Frequent yawning
- C. Respiratory depression
- D. Constipation
Correct Answer: B
Rationale: The correct answer is B: Frequent yawning. Neonatal abstinence syndrome (NAS) is a condition where newborns experience withdrawal symptoms due to exposure to drugs in utero, such as heroin. Frequent yawning is a common sign of NAS, as it indicates central nervous system irritability and overstimulation. Hyporeflexia (A) is not typically seen in NAS, as these babies often exhibit hyperactive reflexes. Respiratory depression (C) is more commonly associated with opioid overdose in neonates rather than NAS. Constipation (D) is a nonspecific symptom and not specific to NAS.
A nurse is providing teaching to a client who has a new prescription for atenolol. Which of the following adverse effects should the nurse include in the teaching?
- A. Lightheadedness
- B. Tachycardia
- C. Dry mouth
- D. Bronchodilation
Correct Answer: A
Rationale: The correct answer is A: Lightheadedness. Atenolol is a beta-blocker that can cause a decrease in blood pressure, leading to lightheadedness due to reduced blood flow to the brain. Tachycardia (choice B) is not an adverse effect as atenolol actually slows down the heart rate. Dry mouth (choice C) is not a common adverse effect of atenolol. Bronchodilation (choice D) is not expected with atenolol as it can actually cause bronchoconstriction in some individuals.