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 C
Explanation
A. There is no need to seal soft toys in a plastic bag for 14 days as impetigo is not typically spread through inanimate objects. However, it is important to discourage the child from scratching the lesions to prevent further spread.
B. Soaking hairbrushes in boiling water is not necessary for the management of impetigo.
Impetigo is caused by bacteria, not lice, so boiling hairbrushes is not a standard recommendation for this condition.
C. This is the correct instruction. Applying a bactericidal ointment (e.g., mupirocin) to the impetigo lesions is a common treatment approach. This helps to eliminate the bacteria causing the infection and promote healing.
D. Administering acyclovir is not indicated for impetigo. Acyclovir is an antiviral
medication used to treat viral infections, such as herpes simplex virus. Impetigo is caused by bacterial infection, not a virus.
Correct Answer is C
Explanation
A. Placing the child in the Trendelenburg position is not necessary for tracheostomy care. In fact, this position is generally not recommended for routine tracheostomy care.
B. Sterile technique, not clean technique, should be used when changing the tracheostomy tube to reduce the risk of infection.
C. This is the correct action. Having the child flex his head can help prevent tension on the tracheostomy ties and ensure a secure and comfortable fit.
D. Full-strength hydrogen peroxide is too harsh and can cause irritation to the skin around the stoma. It is recommended to use normal saline or a mild soap and water solution for cleaning.
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