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.
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Related Questions
Correct Answer is B
Explanation
A. Labrynthitis is an inner ear disorder that causes vertigo, tinnitus, and hearing loss, but it does not typically involve otorrhea (ear discharge) or the sudden resolution of ear pain.
B. A perforated tympanic membrane is characterized by a sudden relief of ear pain when the eardrum ruptures, often accompanied by otorrhea (discharge from the ear). This condition is typically the result of an infection that increases pressure in the middle ear until the eardrum bursts.
C. Meniere disease involves episodes of vertigo, tinnitus, and fluctuating hearing loss, but does not usually present with ear pain followed by discharge.
D. Otitis externa, or swimmer’s ear, involves inflammation of the ear canal with symptoms like pain, itching, and discharge, but does not cause the sudden resolution of pain following the onset of otorrhea.
Correct Answer is A
Explanation
A. Current anticoagulant use is crucial to assess before administering t-PA because combining t-PA with anticoagulants can significantly increase the risk of bleeding complications. It is essential to ensure that the client is not on medications that could interact adversely with t-PA.
B. While blood pressure is important to monitor, it is secondary to assessing anticoagulant use since high blood pressure alone does not contraindicate t-PA administration.
C. A complete neurologic assessment is important for determining the extent of the stroke but is not the immediate priority before administering t-PA.
D. While treatment for peptic ulcer disease is relevant, it is not directly related to the immediate risk factors for t-PA administration compared to anticoagulant use.
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