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. While emotional support is important, this response may come across as directive and may not acknowledge the father's current emotional state.

B. Asking about how the father has handled previous stressors allows him to reflect on coping mechanisms and may provide insight into how he can manage the current situation.

C. While acknowledging the father's feelings is important, agreeing without further exploration may not help him address the emotional distress he is experiencing.

D. Dismissing the father’s feelings or emotions can invalidate his experience, which could prevent him from opening up about his struggles.

A. Asking the client to look away during the injection to reduce anxiety B. Using a larger needle to ensure accurate insulin delivery C. Administering the insulin injection quickly to minimize discomfort D. Explaining the procedure in simple terms to the client before administering the insulin

Correct Answer is D

Explanation

A. Asking the client to look away may reduce anxiety for some, but it does not minimize discomfort or promote understanding.

B. Using a larger needle would likely increase discomfort and is not consistent with atraumatic care, which aims to minimize pain.

C. Administering the injection quickly might reduce discomfort but does not address the child’s emotional needs or ensure proper understanding of the procedure.

D. Explaining the procedure in simple terms helps the child understand what will happen, reducing fear and promoting cooperation. This is an important aspect of atraumatic care.

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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

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