What are the appropriate interventions for a patient experiencing anaphylactic shock from a bee sting? (Select all that apply)
Administer theophylline (aminophylline) intravenously for bronchospasms.
Culture the site of the bee sting and administer antibiotics.
Provide sips of water to moisten the mouth and throat, which is dry from the tachypnea.
Administer diphenhydramine (Benadryl), which is an H1 receptor antagonist.
Prepare for surgical management of the airway.
Correct Answer : A,D,E
Choice A rationale:
Intravenous theophylline (aminophylline) is a bronchodilator that can be life-saving in cases of anaphylactic shock with bronchospasm. It works by relaxing the smooth muscles in the airways, allowing for increased airflow.
Anaphylactic shock can cause severe bronchospasm, which can lead to respiratory failure and death. Theophylline can help to reverse bronchospasm and improve oxygenation.
The dosage of theophylline should be individualized based on the patient's weight and severity of bronchospasm. It is important to monitor the patient's heart rate and blood pressure while administering theophylline, as it can cause tachycardia and arrhythmias.
Choice B rationale:
Culturing the site of the bee sting and administering antibiotics is not appropriate in the acute management of anaphylactic shock. Anaphylaxis is an allergic reaction, not an infection. Antibiotics will not address the underlying cause of the reaction.
Antibiotics may be necessary if the patient develops a secondary infection at the site of the bee sting. However, this is not a priority in the acute setting.
Choice C rationale:
Providing sips of water to moisten the mouth and throat is not a priority in the acute management of anaphylactic shock. The patient's primary concern is likely to be difficulty breathing.
If the patient is able to drink, it is important to ensure that they are able to do so safely without compromising their airway. However, this is not a life-saving intervention.
Choice D rationale:
Diphenhydramine (Benadryl) is an antihistamine that can help to block the effects of histamine, one of the chemicals released during an allergic reaction. This can help to reduce symptoms such as swelling, itching, and hives.
Diphenhydramine can also help to prevent further release of histamine, which can help to stop the progression of the allergic reaction.
Diphenhydramine is available over-the-counter, but it is important to consult a healthcare professional before administering it to a patient in anaphylactic shock.
Choice E rationale:
Surgical management of the airway may be necessary if the patient's airway becomes compromised due to swelling. This could include intubation or a tracheostomy.
It is important to be prepared for surgical airway management in case it is needed. Early preparation can help to prevent delays in treatment and improve the patient's chances of survival.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Respects patient autonomy: This response directly addresses the patient's preference and demonstrates respect for their right to make decisions about their own care. It empowers the patient by offering a solution that aligns with their stated wishes.
Promotes patient comfort: By accommodating the patient's preference, the nurse can help to create a more comfortable and trusting environment, which can lead to better patient outcomes.
Protects patient privacy: Personal hygiene care often involves exposure of sensitive body parts and can be a source of embarrassment or anxiety for some patients. Ensuring that the patient is comfortable with the gender of the caregiver helps to protect their privacy and dignity.
Demonstrates cultural sensitivity: While not explicitly stated in the question, it's possible that the patient's preference is rooted in cultural or religious beliefs. Being sensitive to these factors is essential for providing culturally competent care.
Provides a practical solution: This response offers a concrete solution that can be easily implemented, ensuring that the patient's needs are met in a timely and efficient manner.
Choice B rationale:
May be perceived as intrusive: Asking the patient to explain their reasoning could make them feel uncomfortable or defensive. It's important to respect the patient's right to privacy and not pressure them to disclose personal information.
Could delay care: While understanding the patient's reasons may be helpful in some cases, it's not essential for providing appropriate care. Delaying care to gather this information could potentially compromise the patient's well-being.
Choice C rationale:
Dismisses patient's concerns: This response fails to acknowledge the patient's preference and could make them feel unheard or disrespected. It's important to validate the patient's feelings and concerns, even if you don't fully understand them.
May not address underlying issues: The patient's preference may be based on factors that are not related to the AP's competence or experience. Simply stating the AP's qualifications is unlikely to resolve the patient's concerns.
Choice D rationale:
Defers responsibility: While informing the charge nurse may be necessary for logistical reasons, it's important for the nurse to take ownership of the situation and address the patient's concerns directly. Deferring to another staff member could make the patient feel like their concerns are not being taken seriously.
May delay care: Involving additional staff members could potentially delay the patient's care. It's more efficient to address the patient's preference directly, if possible.
Correct Answer is C
Explanation
Choice A rationale:
Recapping needles is a dangerous practice that significantly increases the risk of needlestick injuries.
The act of recapping involves directing the sharp end of the needle towards one's hand, creating a high likelihood of accidental puncture.
Even experienced healthcare professionals are susceptible to needlestick injuries during recapping.
Wastebaskets are not designed for the safe disposal of sharps and can easily be punctured, leading to potential exposure to bloodborne pathogens.
Choice B rationale:
While it is true that needles should not be recapped on ABG specimens, this option does not address the broader issue of safe needle disposal in general.
Focusing solely on ABG specimens could lead to the misconception that recapping is acceptable for other types of needles.
Choice D rationale:
Breaking needles in half is not recommended as a standard practice for needle disposal.
This action can create sharp fragments that are difficult to handle and can still cause injuries.
Sharps disposal containers are designed to safely contain intact needles and should be used as the primary method of disposal.
Choice C rationale:
Placing uncapped needles directly into a puncture-proof container is the safest and most recommended practice for needle disposal.
These containers are specifically designed to prevent needlestick injuries by shielding the sharps from accidental contact. They are typically made of hard plastic or metal and are clearly labeled for biohazard waste.
Using puncture-proof containers consistently for all needle disposal significantly reduces the risk of needlestick injuries among healthcare workers.
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