The nurse is caring for a client with SOB, wheezes, urticaria, itching and angioedema after receiving vancomycin IV. What is the priority nursing intervention after stopping the medication? Administer:
diphenhydramine 50mg PO.
famotidine 40mg PO.
epinephrine 1mg IM.
a fluid bolus of normal saline.
The Correct Answer is C
A. Diphenhydramine 50 mg PO
Diphenhydramine (Benadryl) treats mild allergic reactions but is not sufficient for anaphylaxis. The presence of SOB and angioedema suggests airway compromise, requiring epinephrine.
B. Famotidine 40 mg PO
Famotidine (H2 blocker) can help with allergic reactions but is not the priority in an emergency.
C. Epinephrine 1 mg IM
Epinephrine is the first-line treatment for anaphylaxis. It reverses airway swelling, hypotension, and bronchoconstriction. The standard IM dose is 0.3-0.5 mg, not 1 mg, but epinephrine remains the priority drug.
D. A fluid bolus of normal saline
IV fluids help treat hypotension in anaphylaxis, but epinephrine is the priority intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Laterally on the left side
Lateral positioning may not fully prevent contractures.
B. Supine with a pillow under the head
A pillow under the head can cause neck contractures.
C. Semi-Fowler’s without a pillow, right arm & hand elevated
Prevents contractures and promotes drainage of edema.
D. Prone without a pillow
Prone position increases discomfort and risk of respiratory complications.
Correct Answer is C
Explanation
A. Massive blood loss leading to decreased oxygen delivery to tissues
This describes hypovolemic shock, which occurs due to significant blood or fluid loss (e.g., hemorrhage, severe dehydration). In this scenario, there is no evidence of massive blood loss, making hypovolemic shock unlikely.
B. Severe allergic reaction causing systemic vasodilation and increased capillary permeability
This describes anaphylactic shock, which results from an acute allergic reaction (e.g., to food, medication, insect stings). There is no mention of an allergen exposure or symptoms like wheezing, stridor, or urticaria, making anaphylactic shock unlikely.
C. Infection causing a systemic inflammatory response leading to vasodilation and decreased tissue perfusion
This patient is exhibiting signs of septic shock, which occurs as a result of a severe infection leading to systemic inflammatory response syndrome (SIRS). The presence of fever, tachycardia, tachypnea, hypotension, and altered mental status strongly suggests sepsis progressing to septic shock.
D. Cardiac failure resulting in inadequate tissue perfusion and oxygenation
This describes cardiogenic shock, which occurs due to heart failure (e.g., from myocardial infarction, cardiomyopathy). It leads to low cardiac output, pulmonary congestion, and organ hypoperfusion. This patient’s infection and systemic inflammation suggest septic shock, not a primary cardiac event.
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