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

Answer and Explanation

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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Correct Answer is C

Explanation

Rationale:

A. "I should do aerobic exercises once per day.": While exercise is beneficial for clients with COPD, it should be individualized and not necessarily done daily, especially in the beginning. Overexertion can worsen symptoms, so gradual and well-monitored activity is recommended.

B. "I will increase my fluid intake to 1,700 milliliters per day.": Clients with COPD are typically encouraged to consume 2,000 to 2,500 mL of fluids daily unless contraindicated. Higher fluid intake helps thin secretions, making them easier to expectorate and improving airway clearance.

C. "I should practice pursed-lip breathing exercises.": Pursed-lip breathing improves ventilation by keeping airways open longer during exhalation, reducing air trapping and dyspnea. It is a fundamental breathing technique taught to clients with COPD to improve oxygenation and control shortness of breath.

D. "I will consume low-protein, low-calorie foods.": Clients with COPD often have increased energy demands due to the work of breathing. A high-protein, high-calorie diet is typically recommended to prevent muscle wasting and support respiratory muscle strength.

A. The restraint tie strap is tied into a knot. B. The restraint is attached to the side rails of the bed. C. The skin under the restraint is cool and has changed color. D. The nurse can insert two fingers under the restraint.

Correct Answer is D

Explanation

Rationale:

A. The restraint tie strap is tied into a knot: Restraint straps should be secured using a quick-release or slipknot, not a firm knot. A tight knot can delay removal in an emergency and increases the risk of injury to the client.

B. The restraint is attached to the side rails of the bed: Attaching restraints to side rails is unsafe, as moving the rails can apply excess force or cause injury. Restraints should be secured to a stable part of the bed frame to prevent unintentional tightening or injury.

C. The skin under the restraint is cool and has changed color: Changes in skin temperature or color can indicate impaired circulation, a serious complication of improper restraint use. These findings require immediate attention and potential removal of the restraint.

D. The nurse can insert two fingers under the restraint: Being able to insert two fingers ensures the restraint is snug but not too tight, allowing adequate circulation and reducing the risk of skin breakdown. This is a standard guideline for safe restraint application.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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