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 C
Explanation
Choice A rationale
White drainage on the eyelids is not a normal finding and should be reported to the surgeon. However, this is not a standard discharge instruction but rather a sign of potential infection.
Choice B rationale
Sleeping on the abdomen is not recommended after cataract surgery as it can increase pressure on the eye and disrupt healing. Patients are usually advised to sleep on their back or the unaffected side.
Choice C rationale
Avoiding lifting anything heavier than 4.5 kg (10 lb) for 1 week is a standard instruction to prevent increased intraocular pressure and ensure proper healing of the surgical site.
Choice D rationale
Bending at the waist to pick up objects can increase intraocular pressure and should be avoided. Patients are advised to bend at the knees instead.
Correct Answer is A
Explanation
Choice A rationale
A phlebotomist who collects blood from clients who have HIV is at the greatest risk for contracting HIV. This is because they are frequently exposed to blood, which is a bodily fluid that can transmit HIV if proper precautions are not taken.
Choice B rationale
A nurse who works for an insurance company and collects urine samples from clients who have HIV is at a lower risk compared to a phlebotomist. Urine is not a common transmission route for HIV.
Choice C rationale
An occupational therapist who works with a client who has HIV is at a lower risk compared to a phlebotomist. Occupational therapists are not typically exposed to blood or other high-risk bodily fluids.
Choice D rationale
A personal trainer who works with a client who has HIV is at a lower risk compared to a phlebotomist. Personal trainers are not typically exposed to blood or other high-risk bodily fluids.
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