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 ["A","B","C","D"]
Explanation
A. Causative agent and duration of exposure – Chemical, electrical, or thermal burns differ in severity.
B. Depth of burn – Superficial, partial-thickness, and full-thickness burns determine severity.
C. Anatomical location – Burns over joints, face, or perineum have higher morbidity.
D. Total Body Surface Area (TBSA) percentage – Used to estimate fluid resuscitation needs (e.g., Parkland formula).
E. Time of day burn occurred – Time does not affect burn severity.
Correct Answer is B
Explanation
Parkland Formula:
Total fluid requirement (ml)=4×Body weight (kg)×Total body surface area burned (%TBSA)
= 4×70×70
=19,600mL (total for 24 hours)
Fluids in first 8 hours: 19,600mL÷2
=9,800mL
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.