A nurse in an emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following actions should the nurse take first?
Obtain pulmonary function tests
Assess the client's blood pressure
Administer epinephrine
Assess the client's level of consciousness
The Correct Answer is C
A. Obtaining pulmonary function tests can help assess the extent of respiratory involvement but is not the immediate priority in an emergency situation like anaphylaxis.
B. Assessing blood pressure is important to monitor for signs of shock, but administering epinephrine takes precedence in treating anaphylaxis.
C. Administering epinephrine is the first-line treatment for anaphylaxis. Epinephrine rapidly reverses the symptoms of anaphylaxis, such as airway constriction and low blood pressure, making it the highest priority intervention.
D. Assessing the client's level of consciousness is important but should occur after the administration of epinephrine, which is critical in reversing the anaphylactic reaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}
Explanation
Intravenous fluid administration is anticipated as hydration can help reduce the viscosity of sickled cells, improving circulation and potentially reducing vaso-occlusive events.
Ice packs to the affected area are nonessential and could potentially be contraindicated, as cold can cause vasoconstriction and may exacerbate pain.
Ambulation is nonessential during acute pain episodes and should be encouraged when the patient is comfortable and pain is controlled.
Hydromorphone IV for pain is anticipated because it is a stronger opioid than morphine and may be necessary if the pain is unresponsive to oral morphine sulfate.
Acetaminophen PO for pain is nonessential in this scenario as it is unlikely to provide adequate pain relief for severe vaso-occlusive pain.
Oxygen therapy is nonessential given the client's SpO2 is 95% on room air, indicating adequate oxygen saturation; however, it may be considered if there is evidence of hypoxia or respiratory distress. It is crucial to monitor the client's response to pain management interventions and adjust the treatment plan accordingly.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Sepsis: The client's low CD4 count indicates a weakened immune system, making them susceptible to infections. The presence of fever, cough, and other symptoms suggests a potential infection, which can lead to sepsis if not treated promptly.
Malnutrition: The client's weight loss, diarrhea, anorexia, and difficulty eating are all signs of malnutrition. A compromised immune system can also contribute to malnutrition.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.