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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Administering hypertonic saline (3% NaCl) is appropriate for treating severe hyponatremia, as it helps to raise sodium levels safely. Restricting water intake is also necessary to prevent further dilution of sodium.
B. Fluid restriction with a loop diuretic may not be effective in this scenario and can worsen the hyponatremia by causing further fluid loss without addressing the sodium levels.
C. Isotonic saline is not indicated for correcting severe hyponatremia, and encouraging oral fluid intake could exacerbate the condition.
D. Increasing oral sodium intake is not sufficient for immediate correction of severe hyponatremia and does not address the acute nature of the client’s symptoms.
Correct Answer is ["A","C","E","H"]
Explanation
The nurse anticipates the following orders from the provider based on the suspected diagnosis:
- A. IV antibiotics: To treat the suspected infection.
- C. Chest x-ray: To assess the lungs for signs of infection, such as pneumonia.
- E. Admit to inpatient: The client's worsening condition and need for aggressive treatment warrant hospitalization.
- H. Complete blood count: To assess the client's overall health status and identify any abnormalities, such as anemia or infection.
Rationale:
- B. Urinalysis: While a urinalysis can be helpful in assessing for urinary tract infections, it is not a priority in this case.
- D. Chest tube placement: This is not indicated unless the client develops a pleural effusion or pneumothorax.
- F. Airborne precautions: This is not necessary for the client's current condition.
- G. Draw an STI lab panel: While this may be relevant for the client's overall health, it is not a priority at this time, especially given the client's acute presentation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.