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 {"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.

A. An unconscious adult client who has no respirations, capillary refill is > 2 seconds, and paramedics have already tried to reposition airway without results B. A conscious adult client who has a broken tibia, blood pressure of 160/90 mm Hg, and heart rate of 118 beats per minute C. An unconscious adult client who has a sucking chest wound, SpO2 of 85%, and capillary refill of < 2 seconds D. A conscious adult client who reports shortness of breath, has a respiratory rate of 24/min, and capillary refill of <2 seconds

Correct Answer is C

Explanation

C. The unconscious adult client with a sucking chest wound and low SpO2 (85%) is in immediate need of intervention. A sucking chest wound is a life-threatening injury that can lead to respiratory distress and compromised oxygenation. This client requires immediate attention to address the chest wound and improve oxygenation.
A. The unconscious client with no respirations and an ineffective airway attempt is likely beyond rescue, making them lower priority compared to those with potentially reversible conditions.
B. The conscious client with a broken tibia and elevated vital signs is stable enough to be seen after more critical cases are addressed.
D. The conscious client with shortness of breath and a high respiratory rate is concerning but not as immediately life-threatening as a client with a sucking chest wound.

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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?

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