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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Not crossing legs is an important self-management strategy for PAD. It helps improve circulation and prevent further vascular damage. This statement is correct.

B. Warm, heavy socks can be harmful for PAD clients because they may reduce circulation. Clients should avoid excessive warmth and use loose-fitting socks instead. This statement indicates misunderstanding.

C. Smoking cessation is crucial for PAD management, as smoking worsens circulation. This statement is correct.

D. Heating pads can be dangerous for clients with PAD due to the risk of burns from impaired circulation. Low settings may still be too high, so this statement requires further education.

A. Client who needs a beta blocker, and has a blood pressure of 98/58 mm Hg. B. Hypertensive client with a blood pressure of 156/90 mm Hg. C. Client who needs pain medication prior to a dressing change of a surgical wound. D. Client who had a first dose of captopril and needs to use the bathroom.

Correct Answer is A

Explanation

A. A client with low blood pressure (98/58 mm Hg) who requires a beta blocker should be seen first because beta blockers can lower blood pressure further, possibly leading to hypotension or dizziness.

B. A hypertensive client with a blood pressure of 156/90 mm Hg is stable and does not require immediate intervention.

C. While pain medication is important, it is not as urgent as addressing a client with low blood pressure and a medication that can worsen the condition.

D. The client who just had captopril can wait to use the bathroom, as the priority is addressing their blood pressure and captopril's effect.

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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?

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Correct Answer is B

Explanation

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Explanation

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