A 9-year-old client presents to the emergency department after a bee sting and experiencing bouts of nausea and vomiting. The nurse notes the client's blood pressure is 68/40 mm Hg, pulse is 148 beats/minute. 02 saturation is 86%, and the child is dyspneic. Which action is the nurse's priority?
Administer benadryl.
Apply ice to the site.
Give epinephrine.
Determine if the sting is in situ
The Correct Answer is C
A. Administering Benadryl may help with allergic reactions but is not the immediate priority when the patient is showing signs of severe hypotension and respiratory distress.
B. Applying ice to the site may help with local swelling but does not address the systemic reaction the child is experiencing.
C. Giving epinephrine is the priority action as it counteracts the anaphylactic reaction, improves blood pressure, and alleviates respiratory distress.
D. Determining if the sting is in situ is less critical than addressing the child's life-threatening symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","F"]
Explanation
A. Small bladder capacity can contribute to enuresis but may not need to be ruled out before addressing psychological factors.
B. Urinary tract infections can cause enuresis and should be evaluated and treated before investigating psychological causes.
C. Stress incontinence typically refers to the involuntary loss of urine due to pressure and may be a psychological factor rather than a physiological cause.
D. Regression can be a behavioral response but is not a medical cause that needs to be ruled out.
E. Cognitive dysfunction can contribute to enuresis but is not primarily a medical cause that needs to be ruled out.
F. Diabetes mellitus can lead to increased urination (polyuria) and should be evaluated as a potential medical cause before considering psychological factors.
Correct Answer is ["A","B","D","E"]
Explanation
A. Washing hands frequently is important for preventing infections, which can trigger a sickle cell crisis.
B. Cold weather can cause blood vessels to constrict, increasing the risk of a sickle cell crisis, making this statement correct.
C. Restricting fluids during illness is not advisable; staying hydrated is crucial for preventing sickle cell crises.
D. Carrying a water bottle encourages adequate hydration, which is essential for individuals with sickle cell anemia to help prevent crises.
E. Taking medications as directed is vital for managing sickle cell disease and preventing complications.
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