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 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.
Correct Answer is D
Explanation
Rationale for Choice A: Obtain vital signs
While obtaining vital signs is important in assessing a patient's overall condition, it is not the first priority in a suspected transfusion reaction.
Vital signs can provide valuable information about the severity of the reaction, but they should not delay the immediate action of stopping the transfusion.
Delaying the cessation of the transfusion could allow for further infusion of incompatible blood or allergens, potentially worsening the reaction and leading to more serious complications.
Rationale for Choice B: Notify the registered nurse
Involving other healthcare professionals is crucial in managing transfusion reactions, but it should not precede stopping the transfusion.
The nurse should prioritize stopping the transfusion to prevent further exposure to potential triggers and then promptly notify the registered nurse for further assessment and interventions.
Timely communication with the registered nurse is essential for coordinating care and ensuring appropriate treatment measures are implemented.
Rationale for Choice C: Administer diphenhydramine
Diphenhydramine, an antihistamine, can be used to treat allergic reactions, but it should not be administered as the first response in this scenario.
The priority is to halt the infusion of the blood product that is potentially causing the reaction.
Administering diphenhydramine before stopping the transfusion could mask the symptoms of the reaction, making it more difficult to assess its severity and progression.
Rationale for Choice D: Stop the transfusion
This is the correct and most immediate action to take when a patient develops itching and hives during a blood transfusion.
These symptoms are indicative of a possible allergic or transfusion reaction, and stopping the transfusion is essential to prevent further complications.
It's critical to act quickly to minimize the amount of incompatible blood or allergens that enter the patient's circulation.
By stopping the transfusion, the nurse can potentially prevent the reaction from worsening and safeguard the patient's well- being.
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.