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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale

Allowing the client to ambulate one day after a detached retinal repair is not recommended. Ambulation can increase intraocular pressure and disrupt the healing process of the retina. The client should be advised to limit physical activity to prevent any strain on the eye.

Choice B rationale

Removing the eye patch during the day is not advisable as it can expose the eye to potential injury or infection. The eye patch helps protect the eye and maintain the correct position for healing. It should be worn as directed by the healthcare provider.

Choice C rationale

Encouraging coughing and deep-breathing exercises is not appropriate for a client who has undergone retinal repair. These activities can increase intraocular pressure and risk detachment of the retina. The client should avoid activities that cause strain or pressure on the eyes.

Choice D rationale

Avoiding reading and writing is crucial for a client one day postoperative following a detached retinal repair. These activities can cause rapid eye movements and strain, which can interfere with the healing process and reattachment of the retina. The client should be advised to rest their eyes and avoid any activities that require intense focus or eye movement.

A. Shut off the intravenous infusion. B. Notify the primary health care provider. C. Have the client take deep breaths and try to relax. D. Obtain a prescription for oral diphenhydramine.

Correct Answer is A

Explanation

Choice A rationale

Shutting off the intravenous infusion is the immediate action to take when a client reports difficulty swallowing during infliximab infusion. This could indicate an infusion reaction or anaphylaxis, which requires immediate cessation of the infusion to prevent further complications.

Choice B rationale

Notifying the primary health care provider is important, but the immediate action should be to stop the infusion to prevent further adverse reactions.

Choice C rationale

Having the client take deep breaths and try to relax is not appropriate in this situation, as it does not address the potential infusion reaction or anaphylaxis.

Choice D rationale

Obtaining a prescription for oral diphenhydramine may be part of the treatment for an infusion reaction, but the immediate action should be to stop the infusion. .

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client 1 day postoperative following a detached retinal repair. Which of the following instructions should the nurse include?

Correct Answer is D

Explanation

A client receiving infliximab through intravenous infusion is reporting difficulty swallowing. Which immediate action would the nurse take?

Correct Answer is A

Explanation

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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?