A nurse is caring for a client who has a peanut allergy. The client states. "I feel like my throat is closing "Which of the following actions should the nurse take?
Deliver 2 L of oxygen via partial nonrebreather mask.
Give epinephrine intramuscularly
Administer diazepam PO.
Notify the radiology department
The Correct Answer is B
Rationale:
A. Deliver 2 L of oxygen via partial nonrebreather mask: While oxygen can support airway function, it does not address the underlying cause of anaphylaxis. Airway closure due to an allergic reaction requires immediate pharmacologic intervention, not just oxygen delivery.
B. Give epinephrine intramuscularly: Epinephrine is the first-line treatment for anaphylaxis. It counteracts bronchoconstriction, airway edema, and hypotension by stimulating alpha and beta receptors, and should be administered immediately when signs of airway compromise are present.
C. Administer diazepam PO: Diazepam is used for anxiety or seizures, not for acute allergic reactions. It has no effect on reversing airway swelling or bronchospasm and would delay the appropriate emergency treatment needed in this situation.
D. Notify the radiology department: Contacting the radiology department is not relevant or urgent in this scenario. The client is experiencing a life-threatening reaction that requires immediate medical intervention, not communication with non-emergency services.
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Related Questions
Correct Answer is C
Explanation
Rationale:
A. Veracity: Veracity refers to the obligation to tell the truth and provide accurate information. While withholding information could also violate this principle, the core issue in this scenario centers more on the client's right to make informed decisions rather than truth-telling alone.
B. Fidelity: Fidelity involves keeping promises and maintaining trust in the nurse-client relationship. While failing to inform the client may strain trust, the request from the parent specifically violates the client's right to participate in decisions about their care.
C. Autonomy: Autonomy is the right of individuals to make informed decisions about their own healthcare. Withholding information about medication side effects directly interferes with the client’s ability to provide informed consent, violating this fundamental ethical principle.
D. Justice: Justice involves fairness and equality in the distribution of care and resources. This principle is not directly implicated in the scenario, as the issue is not about fairness but about the individual’s right to know and decide.
Correct Answer is D,C,B,A
Explanation
Rationale:
D. Inspection: This is always the first step in any physical assessment. The nurse observes the abdomen for contour, symmetry, skin condition, and any visible movements or abnormalities.
C. Auscultation: Performed before palpation to avoid altering bowel sounds. Listening to bowel and vascular sounds provides key information about gastrointestinal activity and blood flow.
B. Light palpation: Conducted next to assess for tenderness, guarding, and superficial masses. This helps ensure client comfort and provides a baseline before deeper pressure is applied.
A. Deep palpation: Done last to evaluate organ size, deep masses, or tenderness. It can stimulate peristalsis or discomfort, so it follows the less invasive steps to minimize changes to assessment findings.
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