A nurse in an emergency department is caring for a client who is suspected to have anaphylaxis following a bee sting.
Which of the following actions should the nurse take first?
Auscultate for wheezing.
Assess the client’s level of consciousness.
Administer epinephrine.
Monitor for hypotension.
The Correct Answer is C
Choice A rationale
Auscultating for wheezing is important but not the first action. The priority is to administer epinephrine to counteract the severe allergic reaction.
Choice B rationale
Assessing the client’s level of consciousness is important but not the first action. Administering epinephrine takes precedence to stabilize the client’s condition.
Choice C rationale
Administering epinephrine is the first action. It is crucial to counteract the severe allergic reaction and prevent further complications.
Choice D rationale
Monitoring for hypotension is important but not the first action. Administering epinephrine is the priority to stabilize the client’s condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A CD4-T-cell count of 180 cells/mm³ indicates severe immunosuppression in a client with HIV, making them highly susceptible to opportunistic infections. This is a critical value that requires immediate attention to prevent life-threatening complications.
Choice B rationale
A positive Western blot test confirms the presence of HIV antibodies but does not indicate the current immune status or the urgency of the client’s condition.
Choice C rationale
Platelets at 150,000/mm³ are within the normal range and do not indicate an immediate threat to the client’s health.
Choice D rationale
A WBC count of 5,000/mm³ is within the normal range and does not indicate an immediate threat to the client’s health.
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
A family history of breast cancer is a significant risk factor because genetic mutations, such as BRCA1 and BRCA2, can be inherited and increase the likelihood of developing breast cancer.
Choice B rationale
Multiparity (having multiple pregnancies) is generally considered to reduce the risk of breast cancer. This is because pregnancy and breastfeeding lower the number of menstrual cycles a woman has, reducing her lifetime exposure to estrogen.
Choice C rationale
Exposure of the chest to high-dose radiation, especially during childhood or young adulthood, increases the risk of breast cancer. Radiation can cause mutations in breast cells, leading to cancer.
Choice D rationale
Previous cancer of the breast, uterus, or ovaries increases the risk of developing breast cancer. This is due to shared risk factors and the possibility of metastasis or recurrence.
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