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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This statement demonstrates an understanding of proper cast care for itch relief. Using a cool air dryer on a low setting can help circulate air and provide relief from itching under the cast. It is important not to use a hot air dryer as it may cause discomfort, skin irritation, or burn. Trickling water or inserting objects into the cast can lead to moisture accumulation and potential complications.
Correct Answer is A
Explanation
After spinal fusion surgery, it is important to limit the patient's activity and movement to allow for proper healing and to prevent complications. The order to have the patient out of bed three times daily and ad lib (as desired) is not appropriate immediately after surgery.
The other orders listed are appropriate for the postoperative care of a patient who has undergone spinal fusion surgery:
- Assess neurological status every 4 hours: This is important to monitor for any changes in neurological function, which could indicate complications such as nerve damage or spinal cord compression.
- Logroll only to change position: Logrolling is a technique used to move patients with spinal fusion surgery while keeping their spine aligned and minimizing stress on the surgical site. This order is appropriate to ensure proper positioning and prevent injury to the surgical area.
- Monitor vital signs every 4 hours: Monitoring vital signs helps to assess the patient's overall condition and detect any signs of complications such as bleeding or infection.
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