A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first?

Stridor

Hypotension

Urticaria

Vomiting

Answer and Explanation

The Correct Answer is A

A. Stridor is a high-pitched sound indicating upper airway obstruction and is a critical sign of anaphylaxis requiring immediate intervention to secure the airway.
B. Hypotension is a serious condition that occurs during anaphylaxis, but the priority is to address the airway obstruction first.
C. Urticaria (hives) is a common symptom of an allergic reaction but is not life-threatening and can be addressed after more severe symptoms.
D. Vomiting may occur during anaphylaxis but is not the most urgent finding when airway compromise is present.

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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. Client reports decreased groin pain of 3 on a 1 to 10 scale. B. The client tolerates a second dose of medication with no greater than 1+ peripheral edema. C. Respirations are unlabored. D. The client's blood pressure when arising from resting position is at premedication levels.

Correct Answer is C

Explanation

A. Decreased groin pain is not an indicator of therapeutic response specific to the effects of epinephrine in treating angioedema.
B. While tolerating a second dose of medication with minimal peripheral edema is positive, it does not directly reflect the immediate therapeutic effects of epinephrine.
C. Unlabored respirations indicate improved airway patency and reduced bronchoconstriction, which are key therapeutic outcomes of epinephrine administration in angioedema.
D. Blood pressure returning to premedication levels is beneficial but is not the most immediate indicator of epinephrine's therapeutic effect in managing angioedema.

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A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first?

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