A nurse is caring for a client who is at risk for anaphylaxis due to bee stings. When reinforcing teaching about the use of an automatic epinephrine injector, which of the following actions is the priority?

The correct answer is choice C: Blood pressure change from 118/78 mm Hg to 86/50 mm Hg.

Choice C rationale: A significant drop in blood pressure can indicate various serious conditions, such as shock, hemorrhage, or a severe infection. The nurse should assess the client further and intervene as necessary to prevent complications.

Choice A rationale: The change in temperature may indicate the onset of a fever and requires further assessment, but it is not as immediately concerning as the sudden drop in blood pressure.

Choice B rationale: The change in respiratory rate could be a result of factors like pain, anxiety, or exercise. While it warrants further assessment, it is not as critical as the blood pressure change.

Choice D rationale: The heart rate change may be a response to medications, rest, or other factors. It should be monitored and assessed, but the priority finding is the blood pressure change, which may indicate a more severe underlying issue.

The client should wear a mask during transport to prevent the spread of infectious droplets. The nurse should wear appropriate personal protective equipment (PPE) based on the precautions required for the specific client, which in this case would be a mask. The nurse does not need to wear a gown as droplet precautions do not require the use of a gown during transport.

The correct answer is choice C, the client should wear a mask during transport.

Choice A rationale:

The client wearing a gown during transport is not typically necessary for droplet precautions unless there is a risk of the gown becoming contaminated with infectious material. Gowns are primarily used to protect the healthcare worker or other patients if there is direct contact with the patient.

Choice B rationale:

While the nurse should wear a mask if they will be within close proximity to the client, the primary concern in droplet precautions is to prevent the spread of infection from the client, who is the source of the droplets.

Choice C rationale:

The client should wear a mask during transport to contain respiratory secretions and minimize the risk of droplet spread, as droplets can be disseminated by coughing, sneezing, or talking. This is a key component of source control in droplet precautions.

Choice D rationale:

Similar to choice A, the nurse wearing a gown during transport is not a standard requirement for droplet precautions unless there is anticipated contact with the patient or their environment that might result in contamination.

In summary, the primary goal of droplet precautions is to prevent the spread of infections through large respiratory droplets that are expelled by the client. Therefore, having the client wear a mask is the most effective measure among the options provided to reduce the risk of transmission during transport.