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 B

Explanation

Rationale:

A. Anger: Anger is typically characterized by blaming others, expressing frustration, or resentment toward the situation, self, or those perceived to be responsible. It often follows denial and precedes bargaining in the stages of grief.

B. Bargaining: The statement "If only I had another day with them" reflects bargaining, a grief stage where individuals dwell on what could have been done differently to prevent the loss. This often includes hypothetical thinking or “what if” scenarios as a way to cope with the pain.

C. Denial: Denial involves refusing to accept the reality of the loss. It may manifest as disbelief or numbness, rather than expressing a desire to have more time or change past events, as seen in this client’s statement.

D. Depression: Depression in grief involves deep sadness, withdrawal, or feelings of hopelessness. While the client may be experiencing sorrow, the focus on "if only" thinking indicates bargaining more than the full emotional weight of depression.

A. Positions the client in a chair before applying the stockings B. Elevates the legs before applying the stockings C. Rolls the extra stocking material down to the client's knee D. Massages the legs before applying the stockings

Correct Answer is B

Explanation

Rationale:

A. Positions the client in a chair before applying the stockings: Applying antiembolic stockings while the client is in a seated position may lead to venous pooling in the lower extremities. This reduces the effectiveness of the stockings and may cause improper fit or increased pressure in dependent areas.

B. Elevates the legs before applying the stockings: Elevating the legs allows venous blood to drain from the lower extremities, reducing swelling and promoting proper application of the stockings. This ensures the stockings provide even compression and help prevent complications like thrombus formation.

C. Rolls the extra stocking material down to the client's knee: Rolling down the stockings creates a tourniquet effect, which can impair circulation and increase the risk of complications like venous stasis or skin breakdown. Stockings should be smooth and free of folds.

D. Massages the legs before applying the stockings: Massaging the legs, especially in a client with phlebitis, may dislodge a clot if present and increase the risk of embolism. Gentle handling without vigorous massage is essential in clients at risk for thromboembolic events.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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