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Nursing interventions and care
Nursing interventions and care ( 7 Questions)
A nurse is caring for a client who has developed an allergic reaction to a medication. Which of the following actions should the nurse take first?
Administer an antihistamine as prescribed. This is an incorrect answer because although administering an antihistamine can help reduce the symptoms of an allergic reaction, it is not the first action that the nurse should take. The nurse should first assess the client's respiratory status and oxygen saturation to determine if they are in respiratory distress or have signs of anaphylaxis.
Stop the medication infusion and disconnect the IV tubing. This is an incorrect answer because although stopping the medication infusion and disconnecting the IV tubing can prevent further exposure to the allergen, it is not the first action that the nurse should take. The nurse should first assess the client's respiratory status and oxygen saturation to determine if they are in respiratory distress or have signs of anaphylaxis.
Assess the client's respiratory status and oxygen saturation. This is the correct answer because the nurse should follow the ABC (airway, breathing, circulation) priority-setting framework when caring for a client who has an allergic reaction. The nurse should first assess the client's respiratory status and oxygen saturation to determine if they are in respiratory distress or have signs of anaphylaxis, which is a life-threatening emergency. The other actions are also important, but they are not the first priority.
Notify the provider and document the incident. This is an incorrect answer because although notifying the provider and documenting the incident are important steps in managing an allergic reaction, they are not the first actions that the nurse should take. The nurse should first assess the client's respiratory status and oxygen saturation to determine if they are in respiratory distress or have signs of anaphylaxis.
No explanation
Assess the client's respiratory status and oxygen saturation. This is the correct answer because the nurse should follow the ABC (airway, breathing, circulation) priority-setting framework when caring for a client who has an allergic reaction. The nurse should first assess the client's respiratory status and oxygen saturation to determine if they are in respiratory distress or have signs of anaphylaxis, which is a life-threatening emergency. The other actions are also important, but they are not the first priority.
A) Administer an antihistamine as prescribed. This is an incorrect answer because although administering an antihistamine can help reduce the symptoms of an allergic reaction, it is not the first action that the nurse should take. The nurse should first assess the client's respiratory status and oxygen saturation to determine if they are in respiratory distress or have signs of anaphylaxis.
B) Stop the medication infusion and disconnect the IV tubing. This is an incorrect answer because although stopping the medication infusion and disconnecting the IV tubing can prevent further exposure to the allergen, it is not the first action that the nurse should take. The nurse should first assess the client's respiratory status and oxygen saturation to determine if they are in respiratory distress or have signs of anaphylaxis.
D) Notify the provider and document the incident. This is an incorrect answer because although notifying the provider and documenting the incident are important steps in managing an allergic reaction, they are not the first actions that the nurse should take. The nurse should first assess the client's respiratory status and oxygen saturation to determine if they are in respiratory distress or have signs of anaphylaxis.