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. Cholelithiasis (gallstones) is a known risk factor for acute pancreatitis, as gallstones can block the bile duct and lead to inflammation of the pancreas.
B. Addison disease is not directly associated with an increased risk of acute pancreatitis. It primarily affects adrenal gland function.
C. Hypothyroidism does not typically influence the risk of developing acute pancreatitis. The condition primarily affects metabolism.
D. Gout is a condition related to elevated uric acid levels and is not a direct risk factor for acute pancreatitis.

A. Restrict the client's intake of sodium. B. Administer vitamin K. C. Reduce the client's intake of protein. D. Administer diuretics.

Correct Answer is C

Explanation

A. Restricting sodium intake is essential in managing ascites and edema in cirrhosis, but it does not directly reduce ammonia levels. Sodium restriction is more related to fluid management rather than ammonia reduction.
B. Administering vitamin K may be necessary for correcting coagulation issues in liver disease, but it does not address the elevated ammonia levels causing encephalopathy.
C. Reducing protein intake is crucial for decreasing ammonia production. In clients with hepatic encephalopathy, proteins are broken down into ammonia, which the impaired liver cannot detoxify effectively, leading to worsened symptoms. Therefore, reducing dietary protein can help lower ammonia levels.
D. Administering diuretics is used to manage fluid retention and ascites in cirrhosis, but it does not directly impact ammonia levels. Diuretics are not the primary intervention for hepatic encephalopathy.

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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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