Exam Guide

Recognizing Anaphylaxis After a New Antibiotic

Foundations of Practice & Clinical Judgment · Question from the ATI PN Fundamentals 2023 Proctored Exam study set

Question: A nurse is assessing a client who is receiving a new antibiotic. Which of the following findings should the nurse identify as requiring immediate follow-up? (Select 4)

Correct answers:

  • Heart rate 104/min
  • Swollen tongue
  • Breath sounds (wheezing)
  • Urticaria

Why this is the answer

Together, tachycardia, angioedema (swollen tongue), bronchospasm (wheezing), and hives (urticaria) indicate a possible anaphylactic/hypersensitivity reaction to the new antibiotic — a medical emergency requiring the medication be stopped and the provider notified immediately.

The bigger concept

'Select 4' items test whether you can pull a cluster of findings together into one urgent picture rather than judging each finding alone. Angioedema and wheezing mean the airway is closing; tachycardia and urticaria confirm a systemic allergic response. At the PN/VN scope the sequence is: stop the infusion, stay with the client, call for the RN and provider immediately, and be ready to assist with epinephrine and oxygen.

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