Question

Nurse is assessing patient following administration of IV penicillin G. Which of the following findings should indicate to the nurse that the patient is experiencing an anaphylactic reaction?

A. Flushing
B. HTN
C. Hallucinations
D. Urinary retention

Answer 1

The symptom that indicates a patient is experiencing anaphylaxis after penicillin G administration is a sudden drop in blood pressure (hypotension), not hypertension. Other signs include swollen tongue or throat, difficulty breathing, or skin reactions like hives.

Step-by-step explanation:

When assessing a patient following the administration of IV penicillin G for signs of an anaphylactic reaction, the nurse should look for symptoms indicative of a severe allergic response. Flushing, while a potential allergic symptom, is not specifically indicative of anaphylaxis. Hallucinations and urinary retention are not typical symptoms of an anaphylactic reaction. On the other hand, hypertension (HTN) is the medical abbreviation for high blood pressure, which does not directly correlate with anaphylaxis, however, a dangerous drop in blood pressure is one of the signs of anaphylactic shock. In the context of anaphylaxis, the most accurate indicator from the given options would be the presence of hypotension or a sudden drop in blood pressure, not hypertension. Therefore, the findings that should indicate to the nurse that the patient is experiencing an anaphylactic reaction include symptoms such as a drop in blood pressure, swollen tongue or throat, difficulty breathing, or skin reactions such as hives.