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 D
Explanation
A. Droplet precautions are not appropriate for anthrax exposure. Precautions would be based on the specific form of anthrax (cutaneous, inhalation, or gastrointestinal).
B. Anthrax is treated with antibiotics, not antiviral therapy. Ciprofloxacin or doxycycline is typically used for prophylaxis and treatment.
C. While assessing for hemorrhage might be relevant in cases of severe anthrax, it is more critical initially to focus on respiratory assessment, particularly for inhalation anthrax.
D. Assessing the respiratory system is crucial for clients exposed to anthrax, particularly inhalation anthrax, as it can cause severe respiratory symptoms and complications. Prompt assessment is essential for early detection and treatment of respiratory distress.
Correct Answer is A
Explanation
A. Monitoring for symptoms of anemia is essential as methotrexate can cause bone marrow suppression, leading to anemia. The nurse should instruct the client to report symptoms like fatigue, pallor, and shortness of breath.
B. Methotrexate is more likely to cause gastrointestinal side effects like nausea and loss of appetite rather than an increase in appetite.
C. Methotrexate is typically administered orally or by injection, not via a patch, so rotating the site of patch application is not relevant.
D. Relief of symptoms from methotrexate generally takes several weeks to months. It is important to set realistic expectations about the timeline for symptom improvement.
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