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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The assessment findings indicate that the client has diminished lung sounds in the lower lobes, suggesting potential postoperative atelectasis or decreased air movement in the lungs. Using an incentive spirometer can help improve lung expansion and prevent respiratory complications such as pneumonia. It is important to address this issue promptly to prevent further deterioration of lung function.
Administering pain medication may be necessary depending on the client's level of pain, but addressing the respiratory issue takes priority in this situation.
Administering the antibiotic earlier than scheduled or changing the dressing over the wound may not be indicated based on the provided assessment findings.
Therefore, having the client use the incentive spirometer is the most appropriate action at this time to promote optimal lung function and prevent respiratory complications.
Correct Answer is A
Explanation
A 3% saline solution is a hypertonic solution used to increase serum sodium levels in cases of severe hyponatremia. However, it can lead to fluid overload and pulmonary edema. The presence of crackles throughout both lung fields indicates the accumulation of fluid in the lungs, which is a serious adverse outcome.
The patient's radial pulse rate of 105 beats/min is within a normal range and does not directly indicate an adverse effect of the saline infusion.
The presence of sediment and blood in the patient's urine may be unrelated to the 3% saline infusion and could indicate other issues such as urinary tract infection or kidney injury.
An increase in blood pressure from 66/50 to 122/74 mmHg is an expected effect of a hypertonic solution like 3% saline, as it can cause an increase in intravascular volume. While the increase in blood pressure is significant, it does not represent an adverse outcome specific to the infusion itself.
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