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. Respiratory acidosis is indicated by the low pH (7.22) and elevated PaCO2 (68 mm Hg), demonstrating that CO2 is retained due to hypoventilation (as seen with a respiratory rate of 7/min). The bicarbonate level is within normal range, suggesting no metabolic compensation is present.
B. Metabolic acidosis would be indicated by a low pH and low bicarbonate level, which is not the case here since the bicarbonate is normal at 26 mEq/L.
C. Metabolic alkalosis would present with a high pH and high HCO3, which does not match these values.
D. Respiratory alkalosis would show a high pH and low PaCO2, which is contrary to the provided ABG results.
Correct Answer is D
Explanation
A. The conversion of RNA into DNA is a critical step in the HIV lifecycle, but it does not directly lead to opportunistic infections; instead, it allows the virus to integrate into the host’s genome.
B. Having reverse transcriptase enzyme is a characteristic of retroviruses like HIV that facilitates replication, but it does not cause opportunistic infections directly.
C. HIV containing a single strand of genetic material is a feature of its classification as a retrovirus but is not related to the risk of opportunistic infections.
D. The ability of HIV to target and destroy CD4 lymphocytes is the key reason for opportunistic infections. CD4 cells are crucial for the immune response, and their depletion leads to immunosuppression, making the client susceptible to infections that would not typically affect an individual with a healthy immune system.
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