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. Defibrillation is used for life-threatening arrhythmias like ventricular fibrillation or pulseless ventricular tachycardia, not for SVT.
B. Cardioversion is appropriate for certain arrhythmias, but in this case, SVT with a stable pulse can be treated initially with medication like adenosine.
C. Adenosine is the first-line treatment for SVT. The typical starting dose is 6 mg IVP, which can be repeated if necessary. Adenosine works by temporarily blocking the electrical conduction through the AV node, allowing the heart to reset to a normal rhythm.
D. A 12 mg dose of Adenosine is used if the 6 mg dose is ineffective, but the 6 mg dose is typically administered first.
Correct Answer is C
Explanation
A. It is appropriate to monitor for symptoms of bradycardia, but the student is currently asymptomatic.
B. Referral to a cardiologist is not necessary unless the student develops symptoms or other concerning signs.
C. Sinus bradycardia can be normal in young, healthy athletes, especially those who engage in regular physical activity. Since the student is asymptomatic, with no signs of dyspnea, chest pain, or other concerning symptoms, there is no reason to restrict participation in sports.
D. Family history may be helpful, but this is not the immediate priority when the student is asymptomatic.
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