A nurse in the emergency department is caring for a school-age child who has developed respiratory stridor, wheezing, and urticaria after receiving an IV medication. Which of the following actions should the nurse take first?
Administer methylprednisolone.
Administer oxygen.
Administer epinephrine.
Administer a nebulized bronchodilator.
The Correct Answer is C
A. Methylprednisolone is a corticosteroid that can help reduce inflammation. While it may be beneficial in some cases of allergic reactions, it is not the first-line treatment for severe
anaphylaxis. In this situation, the priority is to address the immediate symptoms and stabilize the child's condition.
B. Administering oxygen is an important intervention, especially if the child is experiencing respiratory distress. However, in the case of severe anaphylaxis, administering epinephrine is the highest priority as it addresses multiple aspects of the reaction, including airway constriction,
low blood pressure, and hives.
C. This is the correct action. Epinephrine is the first-line treatment for anaphylaxis. It works rapidly to improve breathing, increase blood pressure, and reduce allergic symptoms. It is considered the most critical intervention in this situation.
D. Nebulized bronchodilators can be beneficial for respiratory distress, but they are not the first-line treatment for severe anaphylaxis. Epinephrine is more effective in rapidly reversing the
allergic reaction and stabilizing the child's condition. It addresses a broader range of symptoms in anaphylaxis compared to a bronchodilator.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Abrasions on the knees may be common in active children and may not necessarily indicate physical abuse.
B. Front deciduous teeth missing is a normal occurrence as children lose their baby teeth and grow permanent teeth. It is not indicative of physical abuse.
C. Weight in the 45th percentile indicates that the child's weight falls within the average range for their age. This finding is not indicative of physical abuse.
D. Bruising around the wrists can be a concerning sign, especially if it suggests that the child has been restrained or grabbed forcefully. This finding raises suspicion of physical abuse and should be further assessed and reported if necessary.
Correct Answer is D
Explanation
A. Oliguria (decreased urine output) is not typically associated with hypokalemia. It can be a symptom of other electrolyte imbalances or kidney dysfunction.
B. Hypertension (high blood pressure) is not a typical finding in a child with hypokalemia. Low potassium levels are more likely to be associated with cardiac dysrhythmias and hypotension.
C. Hyperactive bowel sounds are not directly related to hypokalemia. They can occur in various gastrointestinal conditions, but they are not a specific indicator of potassium
levels.
D. This is the correct answer. Hypokalemia (low potassium levels) can lead to decreased neuromuscular excitability, which can result in hyporeflexia (reduced reflexes). This is an important neurological sign associated with low potassium levels.
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