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 D

Explanation

A. Furosemide is a diuretic and is not indicated in the acute management of anaphylaxis.
B. Methylprednisolone is a corticosteroid that may be used later to reduce inflammation but is not the first-line treatment in anaphylaxis.
C. Dobutamine is a medication used to treat heart failure and shock but does not address the acute allergic reaction.
D. Epinephrine is the first-line treatment for anaphylactic shock, as it acts quickly to reverse severe allergic reactions by causing vasoconstriction, bronchodilation, and inhibiting further release of mediators from mast cells.

A. Flushing of the skin B. Oliguria C. Bradypnea D. Hypertension

Correct Answer is B

Explanation

A. Flushing of the skin is not typical in hypovolemic shock; rather, the skin is usually cool and clammy due to vasoconstriction.
B. Oliguria, or decreased urine output, is expected in hypovolemic shock as the kidneys receive less blood flow, leading to reduced urine production.
C. Bradypnea is not a common finding in hypovolemic shock; instead, tachypnea (increased respiratory rate) is typically observed due to compensatory mechanisms for hypoxia and acidosis.
D. Hypertension is not expected in hypovolemic shock; instead, the client typically presents with hypotension due to decreased blood volume and pressure.

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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

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