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 D
Explanation
A. Cortisol levels are not directly affected by furosemide; monitoring for adrenal function is not a priority.
B. Bicarbonate levels are not specifically monitored for clients on furosemide; this medication's main effect does not relate directly to bicarbonate balance.
C. Albumin levels are not primarily affected by furosemide; although low albumin can affect fluid status, it is not the critical monitoring focus.
D. Potassium levels should be monitored because furosemide is a loop diuretic that can lead to hypokalemia, which is a common and significant side effect due to increased renal excretion of potassium.
Correct Answer is D
Explanation
A. Encouraging oral intake may not be effective due to the patient's likely need for more rapid rehydration given his low blood pressure and heart rate.
B. A potassium-sparing diuretic is inappropriate in this situation, as the patient is already experiencing fluid loss and requires rehydration, not diuresis.
C. Restricting fluid intake would be contraindicated as the patient is in a state of dehydration and hypotension.
D. Administering an IV bolus of normal saline is the priority intervention to quickly restore fluid volume and improve blood pressure and hydration status.
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