A client has been diagnosed with shock secondary to an antigen-antibody reaction. What collaborative intravenous intervention has the highest priority?
Administration of norepinephrine IV push
Administration of phosphodiesterase inhibitors
Administration of epinephrine
Administration of antibiotics
The Correct Answer is C
A. Administration of norepinephrine IV push: Norepinephrine is a vasopressor used to treat hypotension in shock, but it does not address the underlying cause of an antigen-antibody reaction. It may be used if hypotension persists after epinephrine, but it is not the first-line treatment. Immediate reversal of the allergic response is more critical.
B. Administration of phosphodiesterase inhibitors: Phosphodiesterase inhibitors improve cardiac contractility and reduce afterload but are not indicated for anaphylactic shock. They do not counteract the systemic effects of a severe antigen-antibody reaction.
C. Administration of epinephrine: Epinephrine is the first-line treatment for anaphylactic shock caused by antigen-antibody reactions. It rapidly reverses vasodilation, bronchodilates, and stabilizes mast cells. Prompt IV or intramuscular administration is essential to prevent cardiovascular collapse and respiratory compromise.
D. Administration of antibiotics: Antibiotics are not indicated unless an infection is the trigger for shock. In antigen-antibody–mediated (anaphylactic) shock, the priority is reversing the allergic reaction. Antibiotics do not address vasodilation, bronchospasm, or histamine-mediated effects.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Salt-wasting syndrome and autonomic dysreflexia: Salt-wasting syndrome is not a common long-term complication of spinal cord injury. Autonomic dysreflexia is a risk, but the combination is inaccurate.
B. Autonomic dysreflexia and orthostatic hypotension: Clients with spinal cord injuries, especially above T6, are at risk for autonomic dysreflexia due to exaggerated sympathetic responses. They also commonly experience orthostatic hypotension because of impaired sympathetic tone. Both conditions require ongoing monitoring and preventive strategies.
C. Deep vein thrombosis and increased intracranial pressure: DVT is a potential risk, but increased intracranial pressure is not typically associated with chronic spinal cord injury. This combination does not reflect the most relevant long-term complications.
D. Orthostatic hypertension and deep vein thrombosis: Orthostatic hypotension, not hypertension, is a common complication in spinal cord injury. DVT is a risk, but the incorrect term for blood pressure regulation makes this inaccurate.
Correct Answer is B
Explanation
A. Lactated Ringer's at 150 mL/hr: Large-volume fluid administration increases preload, which can worsen pulmonary congestion and stress an already failing heart. In cardiogenic shock, the problem is pump failure rather than fluid deficit, making aggressive fluid infusion harmful. This intervention increases myocardial workload instead of reducing it.
B. Morphine sulfate 4 mg IV: Morphine decreases preload and afterload through venous dilation, which reduces the heart’s workload and oxygen demand. It also decreases anxiety and sympathetic stimulation, helping limit further cardiac strain. These effects support myocardial rest and improved efficiency.
C. Norepinephrine 2 mg/min: Norepinephrine causes potent vasoconstriction that raises afterload, forcing the failing heart to pump against greater resistance. This can worsen cardiac workload and oxygen consumption in cardiogenic shock. It is usually avoided unless severe hypotension is present and unresponsive to other treatments.
D. Dobutamine 3 mcg/kg/min: Dobutamine improves contractility and cardiac output, but it also increases myocardial oxygen demand. While helpful for improving perfusion, it does not primarily reduce workload. Its inotropic effect can stress the heart further if not titrated carefully. It is supportive but not the priority intervention for conserving energy.
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