Ten minutes after initiating an intravenous antibiotic, the client complains of shortness of breath, itching, and difficulty swallowing. What is the nurse's initial action?
Prepare to administer prescribed epinephrine
Assess the client's apical pulse and blood pressure
Stop infusing the client's intravenous antibiotic
Administer 4 liters of oxygen via nasal cannula
The Correct Answer is C
A. While epinephrine is crucial in cases of anaphylaxis, it should not be the first action taken. The immediate priority is to stop the offending medication.
B. While assessing vital signs is important, it is not the first action. The primary concern is to halt the exposure to the potential allergen.
C. The first action in this situation should be to immediately stop the infusion of the antibiotic. This prevents further exposure to the allergen and is critical to managing the potential anaphylactic reaction.
D. While providing oxygen may be necessary later if the client is hypoxic, the immediate priority is to stop the infusion of the antibiotic first. Administering oxygen is important but comes after halting the offending agent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Teaching the client about maintaining a healthy weight is crucial, as weight management is a key factor in preventing the progression from prediabetes to type 2 diabetes. Losing even a small percentage of body weight can significantly improve insulin sensitivity and reduce the risk of developing diabetes.
B. At a fasting plasma glucose level of 120 mg/dL, the client is not at the stage where insulin therapy is indicated. Insulin is typically reserved for those with diabetes who require it for glycemic control. The focus should be on lifestyle changes rather than pharmacological treatment at this time.
C. Similar to insulin, oral hypoglycemic agents are generally not prescribed for clients with prediabetes. The goal is to manage blood glucose levels through lifestyle changes, and medication is typically introduced only if the client progresses to diabetes.
D. While self-monitoring of blood glucose is important for individuals with diabetes, it may not be necessary for someone with a fasting plasma glucose level of 120 mg/dL unless specifically indicated by a healthcare provider. Education could include how to monitor if they develop diabetes in the future, but the immediate focus should be on prevention strategies.
Correct Answer is B
Explanation
A. While claudication (muscle cramps with exercise) is common in earlier stages of PAD, it typically occurs in stage II. In stage III, pain often occurs at rest rather than with exertion.
B. In stage III PAD, patients often report rest pain, which can manifest as burning pain in the legs or feet, particularly at night when lying down. This is a hallmark symptom of advanced PAD due to inadequate blood flow.
C. While diminished pulses (like +1) can be found in PAD, this finding alone is not specific to stage III. In advanced stages, pulses may be even weaker or absent.
D. Blackened tissue (necrosis or gangrene) indicates a more severe stage (stage IV) of PAD, where there is critical limb ischemia and tissue death due to a lack of blood flow. Stage III may involve severe pain but usually does not have necrosis.
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.