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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Support the extremity above and below each joint during the exercises: Supporting the limb properly prevents strain on the joints and muscles, reduces pain, and helps maintain proper alignment during passive range-of-motion exercises.
B. Repeat each exercise movement 10 times: Repetitions vary depending on the client’s condition and tolerance. A general guideline is 5 to 10 repetitions, but individualized assessment is important to avoid fatigue or injury.
C. Move each joint just past the point of resistance: Moving a joint beyond the point of resistance can cause pain, injury, or dislocation. Movements should be gentle and stop when resistance or discomfort is felt.
D. Position the bed at mid-thigh level: Bed height should be adjusted for caregiver ergonomics to prevent injury, but "mid-thigh level" is not a standard recommendation for performing range-of-motion exercises.
Correct Answer is ["1.5"]
Explanation
Calculation:
Desired dose = 60 mg.
Available concentration = 50 mg/1.25 mL.
- Calculate the volume in milliliters (mL) to administer.
Volume (mL) = Desired dose (mg) / (Available concentration (mg) / Available volume (mL))
= 60 mg / (50 mg / 1.25 mL)
= 60 mg / 40 mg/mL
= 1.5 mL.
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