A nurse is monitoring a client who received epinephrine for angioedema after a first dose of losartan. Which of the following data indicates a therapeutic response to the epinephrine?

The client tolerates a second dose of medication with no greater than 1 peripheral edema.

Respirations are unlabored.

Client reports decreased groin pain of 3 on a 1 to 10 scale.

The client's blood pressure when arising from resting position is at premedication levels.

Answer and Explanation

The Correct Answer is B

A) The client tolerates a second dose of medication with no greater than 1 peripheral edema:
This does not directly indicate a therapeutic response to epinephrine for angioedema. Angioedema primarily involves swelling of deeper layers of the skin, often around the eyes and lips, and sometimes the throat, which can cause breathing difficulties. Tolerating a second dose of medication with minimal peripheral edema does not specifically address the acute respiratory effects of angioedema.

B) Respirations are unlabored:
This is the correct answer. Angioedema can cause swelling in the airways, leading to difficulty breathing. Epinephrine is used to reduce this swelling and improve airway patency. Unlabored respirations indicate that the airway is not obstructed, which means the epinephrine has successfully alleviated the swelling causing the angioedema.

C) Client reports decreased groin pain of 3 on a 1 to 10 scale:
Decreased groin pain is not relevant to the treatment of angioedema with epinephrine. Pain relief in the groin area does not indicate a therapeutic response to epinephrine, which is primarily used to address airway and anaphylactic symptoms.

D) The client's blood pressure when arising from resting position is at premedication levels:
While epinephrine can affect blood pressure, the main concern with angioedema is airway obstruction rather than blood pressure control. Normalizing blood pressure does not specifically indicate that the epinephrine has successfully treated the angioedema and improved the client's respiratory status.

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Correct Answer is B

Explanation

A) The client with end-stage renal failure scheduled for dialysis is at risk for fluid volume excess rather than deficit. Dialysis is a treatment to remove excess fluid and waste products from the body, which can lead to fluid volume deficit if not managed appropriately, but the scenario does not indicate current dehydration.

B) The client with gastroenteritis and fever is at risk for fluid volume deficit due to fluid loss from vomiting, diarrhea, and fever-induced diaphoresis. Gastroenteritis commonly leads to dehydration, especially when accompanied by fever, which increases fluid loss through sweating.

C) The client with left-sided heart failure and an elevated brain natriuretic peptide (BNP) level is at risk for fluid volume excess rather than deficit. Elevated BNP levels indicate heart failure, which can result in fluid retention and volume overload rather than deficit.

D) The client who has been NPO since midnight for endoscopy is at risk for fluid volume deficit due to fasting. However, the severity and duration of fasting are not specified in the scenario, so it may not present an immediate risk compared to the client with gastroenteritis and fever.

A. A client who has had a cerebrovascular accident B. A client who has had radiation therapy for head and neck cancer C. A client who is 4 hr postoperative following a leg amputation with general anesthesia D. A client who has lactose intolerance E. A client who has had prolonged diarrhea

Correct Answer is ["A","B","C"]

Explanation

A) A client who has had a cerebrovascular accident:
Clients who have had a cerebrovascular accident (stroke) often suffer from dysphagia (difficulty swallowing) due to impaired muscle control or sensory deficits. This makes them more susceptible to aspiration, as food or liquid can enter the airway instead of the esophagus.

B) A client who has had radiation therapy for head and neck cancer:
Radiation therapy in the head and neck area can cause damage to tissues, leading to mucositis, fibrosis, and reduced salivary flow, all of which can impair swallowing function. This increases the risk of aspiration because the normal mechanisms that protect the airway during swallowing may be compromised.

C) A client who is 4 hr postoperative following a leg amputation with general anesthesia:
General anesthesia can depress the gag and cough reflexes and impair coordination of the muscles involved in swallowing, making it more difficult for the client to protect their airway. This increased risk of aspiration is particularly relevant in the immediate postoperative period when the effects of anesthesia may still be present.

D) A client who has lactose intolerance:
Lactose intolerance primarily affects the digestive system and does not directly impact the mechanics of swallowing or increase the risk of aspiration. This condition leads to gastrointestinal symptoms such as bloating, diarrhea, and abdominal pain when consuming lactose-containing foods, but it does not increase the risk of food or liquid entering the airway during eating.

E) A client who has had prolonged diarrhea:
Prolonged diarrhea can lead to dehydration and electrolyte imbalances, but it does not directly affect the swallowing mechanism or increase the risk of aspiration. The primary concern with prolonged diarrhea is fluid and electrolyte management rather than an increased risk of aspiration during eating.

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A nurse is monitoring a client who received epinephrine for angioedema after a first dose of losartan. Which of the following data indicates a therapeutic response to the epinephrine?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is ["A","B","C"]

Explanation

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