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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. A decrease in the Glasgow Coma Scale score from 13 to 10 indicates a significant change in consciousness and may suggest worsening of the brain injury. This is a critical sign that requires immediate reporting and evaluation.
B. Diplopia (double vision) can be a concerning symptom, but it is not as immediately critical as a significant change in the Glasgow Coma Scale score. It still warrants attention but may not be the highest priority.
C. Ataxia (lack of voluntary coordination of muscle movements) is a serious symptom that could indicate worsening of the brain injury but is not as immediately critical as a significant change in the Glasgow Coma Scale score.
D. A drop in heart rate from 76 to 70/min is generally not significant in the context of mild TBI. Changes in heart rate are less critical compared to changes in the level of consciousness.

A. Osteoarthritis B. Place of employment C. Gentamycin D. Naproxen E. Bumetanide F. Heart failure

Correct Answer is ["B","C","D","E"]

Explanation

A. Osteoarthritis is not associated with hearing loss
B. The client's place of employment as a firearms instructor at a shooting range exposes them to loud noises, which is a well-known risk factor for hearing loss.
C. Gentamycin is an aminoglycoside antibiotic that can be ototoxic, especially when administered in high doses or for prolonged periods, potentially leading to hearing loss.
D. Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that has been associated with an increased risk of hearing loss, particularly when taken regularly or in high doses.
E. Bumetanide is a loop diuretic that can also have ototoxic effects, especially when used in conjunction with aminoglycoside antibiotics like gentamycin.
F. Heart failure is not associated with hearing loss

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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