Allergic Reactions
A client develops hives after an antibiotic. Which new finding most clearly indicates progression from a mild allergic reaction to a systemic emergency?
What is airway and/or circulatory involvement, such as stridor, throat swelling, hypotension, or shock?
A client with type 1 diabetes has a pre-exercise glucose of 318 mg/dL and says, “Exercise lowers glucose, so I should go for a run.”
What is delay exercise because the blood glucose is >250 mg/dL?
Two weeks after beginning a new medication, a client develops fever, severe skin pain, dusky lesions, and painful oral ulcers.
What is suspected SJS/TEN rather than a routine medication rash?
A client has chronic leg heaviness, dependent edema, and skin changes caused by ineffective return of blood from the lower extremities toward the heart.
What is chronic venous insufficiency (CVI)?
A client develops calf pain after walking several blocks. Within minutes of stopping, the pain disappears.
What is intermittent claudication?
Minutes after medication administration, a client develops tongue swelling, hoarseness, wheezing, and BP 78/42. Available medications include diphenhydramine, corticosteroids, and epinephrine.
What is IM epinephrine in the outer thigh?
A client repeatedly has morning glucose readings above 200 mg/dL. At 0230, the glucose is 54 mg/dL.
What is the Somogyi effect?
A client develops painful blistering, mucosal lesions, positive Nikolsky sign, and sheet-like epidermal separation involving 8% BSA.
What is Stevens-Johnson syndrome (SJS)?
SJS involves <10% BSA.
One client reports calf pain with walking that stops with rest. Another reports chronic aching and swelling that worsens while the legs are dependent. Which presentation is more consistent with CVI?
What is aching/heaviness with dependent edema?
A client asks, “If PAD is in my legs, why are you worried about my heart and brain?”
What is systemic atherosclerotic disease?
A client's symptoms completely resolve after treatment for anaphylaxis. The nurse continues close observation for several hours because the reaction can recur without another allergen exposure.
What is a biphasic reaction?
A client in DKA has glucose 487 mg/dL, pH 7.21, HCO₃ 14 mEq/L, K⁺ 3.2 mEq/L, and BP 88/52. IV fluids, IV regular insulin, and potassium replacement are prescribed. Which therapy must be delayed?
What is IV insulin?
The same type of severe medication reaction causes epidermal separation involving 35% BSA.
What is toxic epidermal necrolysis (TEN)?
A client with CVI says, “I keep my legs hanging down all evening because gravity helps my circulation.”
What is incorrect teaching?
A client with PAD suddenly develops severe foot pain. The foot is cold and white, and the pedal pulse cannot be detected.
What is acute limb ischemia?
During anaphylaxis, a hypotensive client is placed supine with the legs elevated. The client's respiratory distress immediately worsens.
What is reposition the client because breathing takes priority?
A diabetic client becomes diaphoretic, confused, and unable to swallow. The glucose is 42 mg/dL. Orange juice, oral glucose, IM glucagon, and crackers are available.
What is IM glucagon?
Which intervention should the nurse question in a client with extensive SJS/TEN?
A. Warming the room
B. IV fluid replacement
C. Adhesive ECG electrodes on affected skin
D. Protective/sterile precautions
What is C
Before initiating compression therapy for a client with suspected CVI, the nurse must make sure the client does not have significant impairment of this circulation.
What is arterial circulation/PAD?
A diabetic client with PAD and peripheral neuropathy sleeps with a heating pad against the feet because “they're always cold.”
What is a serious burn/injury risk?
Four clients have allergic symptoms. Which requires immediate epinephrine?
A. Hives and itching, BP 126/76
B. Periorbital swelling with stable respirations
C. Hoarseness, stridor, dysphagia, BP 82/48
D. Localized pruritic rash
What is C?
A client in DKA has an initial K⁺ of 5.2 mEq/L. A student concludes that the client has excess total-body potassium and will not need potassium replacement.
What is total-body potassium depletion despite an initially elevated serum potassium?
A client who recently started a high-risk medication develops fever, severe skin pain, purple-red lesions, oral and ocular ulcerations, loose blisters, and a positive Nikolsky sign. BP remains normal. What should the nurse do first?
What is stop the suspected medication immediately?
A client with a history of CVI suddenly develops an extremely painful, cold, pale foot with an absent pedal pulse. The nurse initially documents “worsening CVI.”
What is acute limb ischemia requiring emergency intervention?
Which client should the nurse assess first?
A. Chronic dependent edema
B. Claudication relieved by rest
C. Sudden severe foot pain with pallor, coldness, and absent pulse
D. Chronic lower-leg discoloration
What is C