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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Weight loss may occur with acute exacerbations but is not a guaranteed effect of prednisone therapy.
B. Prednisone does help reduce inflammation but does not directly relieve abdominal cramping; this statement may reflect a misunderstanding of its action.
C. This statement indicates a clear understanding of the need for gradual tapering of prednisone to prevent withdrawal symptoms and rebound exacerbation.
D. Noticing some medication in the stool is not a common or expected effect of prednisone and may indicate a misunderstanding of how the drug works.
Correct Answer is D
Explanation
A. Back pain may occur but is not typically urgent unless severe; it’s important to monitor but not the priority.
B. Frequent nosebleeds can occur due to dry mucous membranes but are not the most critical symptom to report immediately.
C. Itching of the skin can be managed with moisturizers and does not represent a medical emergency.
D. Feelings of isolation and depression are serious side effects associated with isotretinoin and should be reported immediately due to the risk of self-harm or suicidal thoughts.
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