A nurse is assessing a client after administering a dose of losartan. The client has a hoarse voice, and swollen lips and tongue. In which order should the nurse take the following actions?

Assess the client's airway.

Call the emergency response team.

Apply high-flow oxygen.

Initiate IV access.

Administer IV epinephrine.

Administer IV antihistamines.

Answer and Explanation

The Correct Answer is A,B,C,D,E,F

1. Assessing the client's airway is the priority to determine if there is any obstruction or compromise due to swelling.

2. Calling the emergency response team ensures that additional medical help is on the way if the situation worsens.

3. Applying high-flow oxygen is critical to address potential hypoxia from airway swelling.

4. Initiating IV access is necessary for administering medications.

5. Administering IV epinephrine is essential to counteract severe allergic reactions, such as angioedema.

6. Administering IV antihistamines can help alleviate symptoms but is secondary to the immediate interventions for airway management and epinephrine administration.

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Correct Answer is C

Explanation

A. Anuria, or the absence of urine output, indicates significant renal impairment and is a later sign of shock.
B. Hypotension is a classic sign of shock but occurs after compensatory mechanisms have failed.
C. An increased respiratory rate is often one of the earliest indicators of shock, as the body attempts to compensate for reduced oxygenation and tissue perfusion by increasing respiratory effort.
D. A decreased level of consciousness can occur with prolonged shock but typically presents after other compensatory mechanisms have been overwhelmed.

A. Orthostatic hypotension B. Bradycardia C. Decreased skin turgor D. Weight gain E. Pulmonary edema

Correct Answer is ["A","C"]

Explanation

A. Orthostatic hypotension is a common sign of hypovolemia, as the lack of fluid volume can lead to a drop in blood pressure when changing positions.
B. Bradycardia is not typically associated with fluid volume deficit; tachycardia is more common as the body tries to compensate for low blood volume.
C. Decreased skin turgor is a classic sign of dehydration and fluid volume deficit, indicating reduced skin elasticity.
D. Weight gain is associated with fluid volume overload, not deficit.
E. Pulmonary edema is related to fluid volume overload or congestive heart failure, not hypovolemia.

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A nurse is assessing a client after administering a dose of losartan. The client has a hoarse voice, and swollen lips and tongue. In which order should the nurse take the following actions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?

Correct Answer is C

Explanation

Which of the following signs are commonly associated with fluid volume deficit (hypovolemia)? (Select All that Apply.)

Correct Answer is ["A","C"]

Explanation

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