Nokea
Your client has an allergy to both penicillin and latex. Which of these pathophysiological facts should you apply when you are providing to this client?
- A. The sensitizing dose of penicillin can lead to anaphylaxis.
- B. The second dose of penicillin can lead to distributive shock.
- C. You should be aware of the fact that about 10% of the population has an allergy to both penicillin and latex.
- D. You should be aware of the fact that about 20% of the population has an allergy to both penicillin and latex.
Correct Answer: A
Rationale: A sensitizing dose of penicillin can lead to anaphylaxis , a life-threatening allergic reaction, which is critical to consider when caring for a client with a penicillin allergy. The prevalence of dual allergies (C, D) is not accurate, and distributive shock is not specific to a second dose.
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You will be administering packed red blood cells to your client. Which of the following principles should you apply to this blood administration?
- A. You must insure that the client has a patent intravenous catheter that is at least 20 gauge.
- B. You will need the help of another nurse prior to the administration of these packed red blood cells.
- C. The unit of packed red blood cells should start no more than 1 hour after it is picked up.
- D. You must remain with and monitor the client for at least 30 minutes after the transfusion begins.
Correct Answer: D
Rationale: Remaining with the client for at least 15-30 minutes after starting a blood transfusion is critical to monitor for acute transfusion reactions, such as hemolytic or allergic reactions.
A client who has Ménière's disease is experiencing an acute attack of vertigo. Which of the following interventions should the nurse include in the plan of care?
- A. Darken the client's room and provide a quiet environment.
- B. Provide a low-sodium, bland diet.
- C. Administer an opioid to relieve headache.
- D. Encourage fluid intake to prevent dehydration.
Correct Answer: A
Rationale: A dark, quiet environment reduces stimuli that can exacerbate vertigo in Ménière's disease.
A client with a history of Addison's disease is prescribed hydrocortisone. The nurse should instruct the client to report which of the following side effects immediately?
- A. Weight gain.
- B. Hypoglycemia.
- C. Mood changes.
- D. Muscle weakness.
Correct Answer: C
Rationale: Mood changes may indicate corticosteroid excess, requiring immediate reporting to adjust the hydrocortisone dose.
The nurse is caring for a client with a chest tube. Which observation indicates a potential complication?
- A. Continuous bubbling in the water seal chamber
- B. Tidaling in the water seal chamber
- C. Drainage of 50 mL/hour
- D. Secured dressings around the tube site
Correct Answer: A
Rationale: Continuous bubbling in the water seal chamber suggests an air leak, a potential complication requiring immediate investigation.
A client with a history of depression is prescribed venlafaxine (Effexor). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild headache.
- B. Increased blood pressure.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: Venlafaxine can cause increased blood pressure, requiring immediate reporting to prevent cardiovascular complications.