A 9-year-old client presents to the emergency department after a bee sting and experiencing bouts of nausea and vomiting. The nurse notes the client's blood pressure is 68/40 mm Hg, pulse is 148 beats/minute. 02 saturation is 86%, and the child is dyspneic. Which action is the nurse's priority?
Administer benadryl.
Apply ice to the site.
Give epinephrine.
Determine if the sting is in situ
The Correct Answer is C
A. Administering Benadryl may help with allergic reactions but is not the immediate priority when the patient is showing signs of severe hypotension and respiratory distress.
B. Applying ice to the site may help with local swelling but does not address the systemic reaction the child is experiencing.
C. Giving epinephrine is the priority action as it counteracts the anaphylactic reaction, improves blood pressure, and alleviates respiratory distress.
D. Determining if the sting is in situ is less critical than addressing the child's life-threatening symptoms.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Elevating the affected part is correct and helps reduce swelling and bleeding.
B. Resting the affected area is appropriate and will help minimize movement and further bleeding.
C. Applying heat is not recommended for bleeding episodes as it can increase blood flow and exacerbate bleeding; ice is generally recommended.
D. Compressing the site is appropriate as it helps control bleeding and provides pressure to the affected area.
Correct Answer is D
Explanation
A. Blood pressure can fluctuate and may not accurately reflect fluid loss in an infant, especially in early stages of dehydration.
B. Respiratory rate may increase with distress but is not a direct indicator of fluid loss.
C. Skin integrity can show signs of dehydration, but it is not as definitive as changes in body weight.
D. Body weight is the most reliable indicator of fluid loss, as it reflects changes in fluid status directly and provides a clear measure for assessing hydration.
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