A nurse is caring for a client who develops an anaphylactic reaction to IV antibiotic administration.
After assessing the client’s respiratory status and stopping the medication infusion, which of the following actions should the nurse take next?
Administer epinephrine IM.
Replace the infusion with 0.9% sodium chloride.
Give diphenhydramine IM.
Elevate the clients legs and feet.
The Correct Answer is A
Epinephrine (adrenaline) is the first-line treatment for anaphylaxis, a severe and potentially life-threatening allergic reaction. Epinephrine works by reducing the body’s allergic response and improving the breathing and circulation of the client. Epinephrine should be given as soon as possible after the onset of anaphylaxis symptoms, using an auto-injector device if available.
Choice B is wrong because replacing the infusion with 0.9% sodium chloride (normal saline) is not enough to treat anaphylaxis. Normal saline can help maintain the blood pressure and hydration of the client, but it does not reverse the allergic reaction or improve the breathing of the client. Normal saline can be given after epinephrine, but not before or instead of it.
Choice C is wrong because giving diphenhydramine IM is not enough to treat anaphylaxis. Diphenhydramine is an antihistamine that can help relieve some of the symptoms of anaphylaxis, such as itching and hives, but it works too slowly and does not address the more serious effects of anaphylaxis on the breathing and circulation of the client. Diphenhydramine can be given after epinephrine, but not before or instead of it.
Choice D is wrong because elevating the client's legs and feet is not enough to treat anaphylaxis. Elevating the legs and feet can help increase the blood flow to the vital organs, but it does not reverse the allergic reaction or improve the breathing of the client. Elevating the legs and feet can be done after epinephrine, but not before or instead of it.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is because swelling of the feet can be a sign of lithium toxicity, which is a serious condition that can occur when the level of lithium in the blood is too high. Lithium toxicity can cause confusion, irregular heartbeat, muscle weakness, and kidney problems. Therefore, the client should report any signs of lithium toxicity to their provider as soon as possible.
Choice A is wrong because limiting foods containing tyramine is not necessary for clients taking lithium. Tyramine is a substance found in some foods that can interact with certain antidepressants called monoamine oxidase inhibitors (MAOIs), but not with lithium.
Choice B is wrong because decreasing the daily sodium intake can actually increase the risk of lithium toxicity.
Sodium helps to regulate the amount of lithium in the body, so if the sodium level is low, the lithium level can rise too high.
The client should maintain a normal sodium intake and drink enough fluids while taking lithium.
Choice C is wrong because taking this medication 2 hours before a meal is not required for clients taking lithium.
Lithium can be taken with or without food, but it should be taken at the same time each day to keep a steady level in the blood.
Taking lithium 2 hours before a meal may cause stomach upset, which is a common side effect of lithium.
Correct Answer is D
Explanation
Saw palmetto is a natural herbal supplement that may help reduce the symptoms of benign prostate hypertrophy (BPH) by inhibiting the enzyme 5- alpha-reductase, which converts testosterone to dihydrotestosterone (DHT), a hormone that stimulates prostate growth. Some studies have shown that saw palmetto can improve urinary flow and reduce nocturia in men with BPH.
Choice Ais wrong because black cohosh is a plant that contains phytoestrogens, which are compounds that mimic estrogen in the body.Black cohosh is mainly used for menopausal symptoms in women, such as hot flashes and mood swings.
Choice Bis wrong because garlic has no proven effect on BPH. Garlic may have some benefits for cardiovascular health and immune system, but it does not affect prostate size or function.It has no effect on BPH and may even worsen it by altering the hormonal balance.
Choice C is wrong because feverfew is a herb that has anti-inflammatory and anti-migraine properties.
It may help prevent or treat headaches, arthritis, and allergies, but it has no effect on BPH or urinary symptoms.
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