A nurse in an emergency department is caring for an adolescent who is experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse?

Elevate the head of the child's bed.

Administer IM epinephrine to the child.

Determine the allergen that caused the child's reaction

Insert a large bore IV catheter for the child.

Answer and Explanation

The Correct Answer is B

A. Elevating the head of the bed may be useful after airway management but is not the priority in anaphylaxis.

B. Administering IM epinephrine is the priority action in anaphylaxis, as it works rapidly to reverse the symptoms by constricting blood vessels, relaxing smooth muscles, and improving breathing.

C. Determining the allergen is important for future prevention, but the immediate priority is treating the reaction.

D. While establishing IV access is important for fluid resuscitation, it is not the priority over administering epinephrine in anaphylaxis.

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Correct Answer is B

Explanation

A. The CRIES scale is used for neonates and infants, not toddlers.

B. The FACES pain rating scale is appropriate for children aged 3 years and older, allowing them to express their pain visually through faces showing different expressions.

C. The Noncommunicating children's pain checklist is used for older children with communication impairments.

D. The Numeric pain rating scale is more suitable for older children and adults who can understand and use numbers to rate pain.

A. Dyspnea B. Heart rate C. Blood pressure D. Oxygen saturation E. Respiratory rate F. Oral intake G. Lung sounds

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"B"}}

Explanation

Assessment Finding	Improved	No change
Dyspnea		✅
Heart rate	✅
Blood pressure	✅
Oxygen saturation	✅
Respiratory rate	✅
Oral intake	✅
Lung sounds		✅

Rationale:

Improved:

Heart rate and blood pressure are slightly improved by 1930, likely due to the medications (furosemide, enalapril) helping manage fluid retention and blood pressure.

Oral intake has improved, but monitoring of this is critical given the recent lack of eating for several days.

No change:

Dyspnea remains unchanged, since the adolescent is still dyspneic with activity.

Lung sounds remain unchanged, indicating that there may still be some wheezing or fluid buildup in the lungs.

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A nurse in an emergency department is caring for an adolescent who is experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing the pain level of a 3-year old toddler. Which of the following pain assessment scales should the nurse use?

Correct Answer is B

Explanation

Exhibits The nurse reviews the client’s medical record from admission to 1930 hrs. Click to indicate whether the assessment finding has improved or not changed.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"B"}}

Explanation

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