A client, receiving a dose of penicillin for an infection, begins to complain of difficulty breathing and has a respiratory rate of 38. This client is experiencing what type of reaction?
1. Type 1
2. Type 2
3. Type 3
4. Type 4
1
An anaphylactic reaction is a type 1 reaction. Type 2 reactions are cytotoxic and are seen with blood transfusions. Type 3 reactions are immune related and are associated with rheumatoid arthritis or systemic lupus erythematosus. Type 4 reactions are seen with transplant rejections.
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The nurse is performing an abdominal assessment on a client who had been previously diagnosed with cirrhosis. As the nurse inspected the client's abdomen and notes ascites. Based on this data, which interventions will the nurse perform next?
Select all that apply. 1. Obtain stool specimen for occult blood. 2. Measure the client's abdominal girth. 3. Obtain stool specimen for culture and sensitivity. 4. Bilateral leg measurements. 5. Percuss the abdomen at midline.
Which hematological finding for a pregnant woman requires immediate referral for further evaluation?
a. increased white blood cell (WBC) and red blood cell (RBC) volume b. increased fibrinogen and clotting factors VII through X c. low platelets, hemolysis, and elevated liver enzymes d. increased plasma volume and decreased hematocrit
A client recently had a mammogram. Which statement by the client indicates a need for clarification regarding the importance or purpose of this procedure?
a. "Now that I have had a mammogram, my risk for getting breast cancer is reduced." b. "I will still do a breast self-examination monthly even after the mammogram." c. "Yearly mammograms can reduce my risk of dying from breast cancer." d. "The amount of radiation exposure from a mammogram is very low."
A nurse has been caring for an 83-year-old resident of a nursing home for 2 years and has developed a high level of trust with the resident. Which of the following recent changes in the resident's behavior may signal the possibility of hearing loss?
A) The resident's statements occasionally suggest that he is not oriented to time. B) The resident had a recent episode where he became visibly angry at a nursing assistant. C) The resident's attention span is short and he is easily distracted. D) The resident has become increasingly disagreeable and terse in his demeanor.