Which assessment information is most important for the nurse to obtain when evaluating whether treatment of a patient with anaphylactic reaction has been effective?

Blood Pressure

Oxygen Saturation.

Heart Rate.

Orientation.

Answer and Explanation

The Correct Answer is A

Anaphylaxis is a severe and potentially life-threatening allergic reaction that can lead to a rapid drop in blood pressure, known as hypotension. This drop in blood pressure is a critical indicator of the severity of the reaction and the effectiveness of the treatment provided. The nurse needs to monitor the patient's blood pressure closely to ensure it stabilizes and returns to a safe range.

While oxygen saturation, heart rate, and orientation are also important parameters to assess, they are secondary to blood pressure in evaluating the effectiveness of treatment for anaphylaxis. Oxygen saturation can help determine the adequacy of oxygenation, heart rate can indicate the presence of tachycardia (which may be a sign of an ongoing reaction or hypoperfusion), and orientation can provide information about the patient's mental status and potential complications.

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Correct Answer is A

Explanation

The patient's vital signs indicate signs of septic shock, including low blood pressure (70/46 mm Hg), tachycardia (136 beats/min), and tachypnea (32 breaths/min). The patient also has a high temperature of 104°F, indicating a fever. These findings suggest a systemic response to an infection that is leading to inadequate tissue perfusion.The initial treatment for septic shock includes fluid resuscitation to improve blood pressure and tissue perfusion. A fluid bolus of 0.9% Sodium Chloride (normal saline) is commonly used to restore intravascular volume in septic shock. It helps to increase blood pressure, improve organ perfusion, and stabilize the patient's condition.

The other interventions, such as administering Pantoprazole (Protonix) for gastrointestinal protection, giving Acetaminophen (Tylenol) for fever control, or administering rapid-acting insulin per sliding scale for hyperglycemia, are important aspects of care but should be implemented after the initial fluid resuscitation. The priority at this moment is to address the patient's hypotension and inadequate tissue perfusion through the administration of fluid bolus.

A. Urine output 200 mL over the last 4 hours. B. Decreasing serum albumin levels. C. Weight gain of 0.75 kg in the last 2 days. D. Sodium (Na) level 128 mEq/L.

Correct Answer is C

Explanation

Weight gain is a positive indicator of improved nutritional status. It suggests that the client is receiving adequate nutrition and their body is able to build up and retain weight. This is particularly important in the case of protein-calorie malnutrition, as it indicates that the client is receiving sufficient protein and calories to support their nutritional needs.

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Which assessment information is most important for the nurse to obtain when evaluating whether treatment of a patient with anaphylactic reaction has been effective?

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Naxlex Comprehensive Predictor Exams

A patient with sepsis has a BP of 70/46 mm Hg, pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104°F, and blood glucose of 245 mg/dL. Which intervention ordered by the health care provider should the nurse implement first?

Correct Answer is A

Explanation

A client is admitted with protein-calorie malnutrition and is receiving supplemental feedings through a naso-duodenal tube. Which assessment finding indicates that the client's nutritional status is improving?

Correct Answer is C

Explanation

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