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 B

Explanation

A. Flushing of the skin is not typical in hypovolemic shock; rather, the skin is usually cool and clammy due to vasoconstriction.
B. Oliguria, or decreased urine output, is expected in hypovolemic shock as the kidneys receive less blood flow, leading to reduced urine production.
C. Bradypnea is not a common finding in hypovolemic shock; instead, tachypnea (increased respiratory rate) is typically observed due to compensatory mechanisms for hypoxia and acidosis.
D. Hypertension is not expected in hypovolemic shock; instead, the client typically presents with hypotension due to decreased blood volume and pressure.

A. Abuse B. Battery C. Malpractice D. Assault

Correct Answer is C

Explanation

A. Abuse refers to the mistreatment of a patient, which does not apply to this scenario as the issue was an error rather than intentional harm.
B. Battery involves intentional and wrongful physical contact with another person; while the wrong medication is harmful, it was not an intentional act of violence.
C. Malpractice is the correct choice because it involves negligence in the professional duties of a healthcare provider, resulting in harm to a patient. The nurse failed to adhere to the standard of care by administering the incorrect medication.
D. Assault refers to the threat of harm or the act of creating fear of harm in another person, which is not applicable in this scenario since the nurse did not threaten the client.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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