A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is initiated. In which, order should the nurse implement these interventions? (Arrange the actions in order of priority, with the highest priority first, and the least priority last or at the bottom.)
Stop the Infusion.
Assess vital signs
Contact the healthcare provider.
Initiate an adverse event report.
Document reaction to the drug.
The Correct Answer is A,B,C,D,E
A) This is because the client is experiencing an allergic reaction to piperacillin, which can be life-threatening. The nurse should stop the infusion immediately to prevent further exposure to the drug and assess vital signs to monitor for signs of anaphylaxis, such as hypotension, tachycardia, wheezes, or stridor.
B) Assessing vital signs is a priority to determine the severity of the reaction and the client's overall condition.
C) The nurse should contact the healthcare provider to report the situation and obtain orders for treatment, such as antihistamines, corticosteroids, or epinephrine.
D) The nurse should initiate an adverse event report to document the incident and follow the facility's protocol for reporting medication errors.
E) The nurse should also document the reaction to the drug in the client's chart and notify the pharmacy to avoid future administration of piperacillin or related antibiotics.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Tracheostomy care is done to keep the trach tube clean and prevent infections.It involves suctioning and cleaning parts of the tube and the skin around the stoma. A code blue is a hospital emergency code that indicates a life-threatening situation, such as cardiac or respiratory arrest.It requires immediate attention from trained personnel.
- Call for an assistant to stay with the client who is receiving tracheostomy care and continue the procedure.
- Respond to the code blue and assist with resuscitation efforts for the other client.
- Return to the client who is receiving tracheostomy care as soon as possible and complete the procedure.
Therefore, the correct answer isa. Call for an assistant.
Correct Answer is C
Explanation
Emphysema is a chronic obstructive pulmonary disease (COPD) characterized by the destruction of lung tissue and loss of elasticity in the alveoli. This leads to poor gas exchange, specifically the reduced ability of oxygen to enter the bloodstream and carbon dioxide to be eliminated from the body. Impaired gas exchange can result in hypoxemia and hypercapnia, leading to symptoms such as shortness of breath, fatigue, and decreased exercise tolerance.
While self-care deficit, activity intolerance, and ineffective airway clearance are all potential complications associated with emphysema, impaired gas exchange is the priority due to its direct impact on the client's oxygenation and overall respiratory function.
Addressing impaired gas exchange and optimizing oxygenation is essential to support the client's respiratory health and prevent further complications. Management strategies for impaired gas exchange may include administering supplemental oxygen, implementing respiratory treatments to improve lung function, and providing education on breathing techniques and energy conservation.
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