A nurse is caring for a client who is experiencing an allergic reaction to a medication. Which of the following interventions should the nurse prioritize?
Administering an antihistamine
Notifying the healthcare provider
Monitoring vital signs
Applying a cool compress to the affected area
The Correct Answer is A
Explanation: When a client experiences an allergic reaction, monitoring vital signs is a priority nursing intervention. An allergic reaction can lead to systemic manifestations, such as respiratory distress, hypotension, or tachycardia. Monitoring vital signs allows the nurse to assess the client's overall condition, identify any worsening symptoms, and provide prompt intervention.
A) Administering an antihistamine
While antihistamines may be a part of the treatment plan for allergic reactions, they should not be the nurse's initial priority. The nurse should first assess the client's vital signs and overall stability before administering any medication.
B) Notifying the healthcare provider
While it is important to communicate with the healthcare provider, especially in severe cases, immediate intervention to monitor vital signs and ensure client stability should take precedence before notifying the healthcare provider.
D) Applying a cool compress to the affected area
Applying a cool compress may provide local relief for symptoms such as itching or redness. However, in the case of an allergic reaction, systemic manifestations require immediate attention. Therefore, monitoring vital signs takes priority over local comfort measures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
No explanation
Correct Answer is A
Explanation
Answer: A. Inject the epinephrine into your thigh muscle and hold it for 10 seconds. This is the correct answer because the thigh muscle is the preferred site for administering epinephrine in case of anaphylaxis. The thigh muscle has a large blood supply and can absorb the medication quickly. The nurse should instruct the client to inject the epinephrine into the middle of the outer thigh, at a 90-degree angle, and hold it for 10 seconds to ensure that the full dose is delivered.
B) Inject the epinephrine into your upper arm muscle and hold it for 5 seconds. This is an incorrect answer because the upper arm muscle is not a recommended site for administering epinephrine in case of anaphylaxis. The upper arm muscle has a smaller blood supply and may not absorb the medication as quickly as the thigh muscle. The nurse should instruct the client to inject the epinephrine into the thigh muscle instead.
C) Inject the epinephrine into your abdomen and hold it for 15 seconds. This is an incorrect answer because the abdomen is not a recommended site for administering epinephrine in case of anaphylaxis. The abdomen has more fat tissue and may not absorb the medication as quickly as the thigh muscle. The nurse should instruct the client to inject the epinephrine into the thigh muscle instead.
D) Inject the epinephrine into your buttock and hold it for 20 seconds. This is an incorrect answer because the buttock is not a recommended site for administering epinephrine in case of anaphylaxis. The buttock has more fat tissue and may not absorb the medication as quickly as the thigh muscle. The nurse should instruct
the client to inject the epinephrine into the thigh muscle instead.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.