Your patient with Iron deficiency anemia is receiving Iron Dextran when their blood pressure suddenly starts to drop, their respiratory rate increases, and their breath becomes wheezy- sounding. Your PRIORITY intervention will be:

Provide calm reassurance while reassessing blood pressure

Administer Epinephrine 1:1.000 IM

Place on Nasal Cannula 6 Lpm

Raise the HOB to high fowlers

Answer and Explanation

The Correct Answer is B

A.   While it’s important to provide reassurance, this option does not directly address the acute symptoms of respiratory distress and hypotension. Monitoring blood pressure is essential, but immediate action to treat the underlying issue is more critical.
B.   This is the priority intervention in the case of suspected anaphylaxis. Epinephrine acts quickly to counteract severe allergic reactions, relieving bronchospasm, increasing heart rate, and raising blood pressure. Given the patient's wheezing and hypotension, administering epinephrine is crucial.
C.   Administering oxygen can be beneficial, especially if the patient is experiencing respiratory distress. However, it does not address the potential anaphylactic reaction or the drop in blood pressure directly. It should be part of the management but not the priority.
D.   Elevating the head of the bed can help improve breathing, especially if the patient is in respiratory distress. However, this action alone does not address the potential life-threatening aspects of anaphylaxis.

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Correct Answer is D

Explanation

A. While monitoring drug levels is important, sending a trough level before the initial dose is not standard practice. Trough levels are typically checked just before the next dose of a medication is given, especially for antibiotics like Gentamicin that require monitoring for potential toxicity. Therefore, this option is not the best immediate action.
B. While managing the environment and ensuring patient privacy is important, this option does not address any immediate medical needs related to starting the antibiotic infusion.
C. Educating the patient about potential side effects is essential for informed consent and patient safety. However, while important, this is not the most critical action to take prior to the infusion.
D. Before starting an antibiotic treatment, it is crucial to send a culture and sensitivity test to identify the specific pathogen causing the infection. This ensures that the selected antibiotic (Gentamicin) is appropriate for the identified bacteria, which is vital for effective treatment and to avoid antibiotic resistance.

A. 30 minutes B. 90 minutes C. 15 minutes D. 60 minutes

Correct Answer is C

Explanation

A. This is incorrect because the time limit is shorter than 30 minutes.
B. This is also incorrect. You need to start the transfusion sooner than this timeframe.
C. You should start the transfusion within 15 minutes after the blood product is issued from the blood bank. This guideline is critical to minimize the risk of bacterial growth and ensure the safety of the transfusion.
D. The time limit is shorter than 60 minutes, emphasizing the urgency in starting the transfusion to maintain the integrity of the blood product.

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Your patient with Iron deficiency anemia is receiving Iron Dextran when their blood pressure suddenly starts to drop, their respiratory rate increases, and their breath becomes wheezy- sounding. Your PRIORITY intervention will be:

Nursing Test Bank

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Correct Answer is D

Explanation

You are planning to transfuse a unit of PRBC's to your patient. You know that when you arrive at the blood bank and they hand you the unit of blood, you have how long to start the transfusion from that time?

Correct Answer is C

Explanation

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