ATI_RN_Fundamentals

Question 1: A nurse is caring for a client. Exhibit 1 Nurses' Notes 0800: Exhibit 2 Vital Signs 0830: Exhibit 3 Antibiotic administered as prescribed. Bilateral breath sounds clear and present throughout. The client reports itching over the chest area and has urticaria over the chest and trunk. The client states tongue feels swollen. Bilateral breath sounds with scattered wheezing upon auscultation. Select the 4 findings that require immediate follow-up. A. Urticaria B. Swollen tongue C. Bilateral breath sounds with scattered wheezing upon auscultation D. Respiratory rate. Explanation Urticaria over the chest and trunk, a swollen tongue, and bilateral breath sounds with scattered wheezing upon auscultation all require immediate follow-up. These symptoms may indicate an allergic reaction to the antibiotic that was administered. Choice D, respiratory rate, is not an answer because there is no information provided about the respiratory rate in the question.