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. Increasing the infusion rate may exacerbate the patient's symptoms and does not address the potential toxicity from the furosemide.
B. Normal potassium levels indicate that potassium supplementation is unnecessary and does not address the dizziness and ringing in the ears, which could suggest ototoxicity from furosemide.
C. While reassurance can help, the patient's symptoms indicate a potential adverse reaction to the medication that should not be ignored.
D. Stopping the furosemide infusion and notifying the provider is the most appropriate action due to the risk of ototoxicity and the need for further evaluation of the patient's symptoms.
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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