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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Binding is the initial step where the HIV virus attaches to the CD4 receptor on the host cell's surface. This interaction is crucial for the subsequent entry of the virus into the host cell.
B. Integration occurs later in the lifecycle, after the virus has entered the host cell and its RNA is converted to DNA.
C. Fusion refers to the process where the viral envelope fuses with the host cell membrane to allow entry into the cell, which follows the binding stage.
D. Reverse Transcription is the process of converting viral RNA into DNA after the virus has entered the host cell, and is not involved in the attachment phase.
Correct Answer is B
Explanation
A. Respiratory alkalosis is characterized by a high pH and low PaCO2, which is not evident in this scenario where the pH is low and PaCO2 is elevated.
B. The low pH of 7.3 indicates acidemia, and the elevated PaCO2 of 50 mm Hg suggests respiratory acidosis, where the body is retaining carbon dioxide, leading to an increase in acidity.
C. Metabolic acidosis would present with a low pH and a normal or decreased PaCO2, which is not the case here since the PaCO2 is elevated.
D. Metabolic alkalosis would show a high pH and elevated HCO3 levels, which is not consistent with the given ABG results.
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