A client is in the hospital and has received two doses of an angiotensin-converting enzyme (ACE) inhibitor for hypertension. When the nurse answers the client's call light, the client presents an appearance as shown below. What action by the nurse is most appropriate?
Administer epinephrine 1:1000, 0.3 mg IV push immediately.
Reassure the client that these symptoms will go away.
Ensure a patent airway while calling the Rapid Response Team.
Apply oxygen by facemask at 100% and a pulse oximeter.
The Correct Answer is C
A. Epinephrine is used in cases of severe allergic reactions or anaphylaxis, and while it may be appropriate in treating angioedema, the first priority is to ensure the airway is clear and that the client can breathe. Administering epinephrine may be part of the treatment plan but should follow securing the airway and calling for immediate advanced help.
B. This is not appropriate because angioedema can be life-threatening and can rapidly progress to airway obstruction. Reassurance without action would delay necessary interventions and could jeopardize the client’s safety.
C. In cases of angioedema, airway obstruction is the most dangerous complication, as it can lead to asphyxiation. The nurse's first priority is to ensure that the patient's airway remains open and clear. The nurse should immediately call the Rapid Response Team (RRT) for urgent medical intervention, which may include medications (like epinephrine), intubation, or other interventions. Ensuring the airway is open and calling for advanced help are the most critical first steps in managing severe cases of angioedema.
D. While oxygen therapy may be appropriate if the client shows signs of respiratory distress or hypoxia, the immediate concern is securing the airway. Oxygen may be needed after ensuring the airway is open, but the priority is to avoid airway obstruction first. The nurse should secure the airway and then administer oxygen if needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Measuring abdominal girth can help monitor the aneurysm.
B. Auscultation is safe and may reveal bruits associated with aneurysms.
C. Palpation of the abdominal midline area is dangerous and can risk rupturing the aneurysm, requiring further education.
D. Observation is non-invasive and safe.
Correct Answer is D
Explanation
A. Increasing normal saline infusion is appropriate for treating dehydration and hypovolemia.
B. Collecting blood cultures and administering antibiotics is appropriate for treating possible sepsis, given the fever and elevated WBC count.
C. Collecting a urine sample for culture and sensitivity is appropriate to investigate a potential urinary source of infection.
D. Administering furosemide, a diuretic, is inappropriate in a client with signs of dehydration and hypovolemia (e.g., low CVP and PAWP) as it can worsen fluid depletion.
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