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","B"]
Explanation
Choice A rationale
Intubation equipment and oxygen are essential for managing airway obstruction and ensuring adequate oxygenation in a patient experiencing anaphylaxis due to a severe peanut allergy.
Choice B rationale
Epinephrine is the first-line treatment for anaphylaxis as it rapidly reverses the symptoms by constricting blood vessels, relaxing muscles in the airways, and reducing swelling.
Choice C rationale
Blood administration equipment is not typically required for managing anaphylaxis unless there is a concurrent condition that necessitates it.
Choice D rationale
A Foley catheter is not relevant to the immediate management of anaphylaxis.
Correct Answer is D
Explanation
Choice A rationale
Diphenhydramine does not expand blood volume. It is an antihistamine used to prevent allergic reactions.
Choice B rationale
Diphenhydramine does not enhance clotting factors. It is used to manage allergic reactions.
Choice C rationale
While diphenhydramine can help manage fever and chills, its primary purpose before a blood transfusion is to prevent allergic reactions.
Choice D rationale
Administering diphenhydramine before a blood transfusion helps prevent urticaria and other allergic reactions by blocking histamine release. .
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