A nurse in an emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following actions should the nurse take first?

Obtain pulmonary function tests

Assess the client's blood pressure

Administer epinephrine

Assess the client's level of consciousness

Answer and Explanation

The Correct Answer is C

A. Obtaining pulmonary function tests can help assess the extent of respiratory involvement but is not the immediate priority in an emergency situation like anaphylaxis.
B. Assessing blood pressure is important to monitor for signs of shock, but administering epinephrine takes precedence in treating anaphylaxis.
C. Administering epinephrine is the first-line treatment for anaphylaxis. Epinephrine rapidly reverses the symptoms of anaphylaxis, such as airway constriction and low blood pressure, making it the highest priority intervention.
D. Assessing the client's level of consciousness is important but should occur after the administration of epinephrine, which is critical in reversing the anaphylactic reaction.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"E"}

Explanation

Pneumonia: The client is at risk for pneumonia due to decreased lung expansion and increased risk of aspiration, especially after abdominal surgery.

Deep vein thrombosis (DVT): The client is at risk for DVT due to prolonged immobility and the increased risk of blood clots associated with surgery.

Urinary retention: The Foley catheter may interfere with the client's ability to void normally, increasing the risk of urinary retention.

A. Administer desmopressin acetate 0.2 mg orally B. Maintain an intravenous (IV) infusion of 0.45% sodium chloride C. Restrict fluid intake to 1,000 mL per day D. Provide a diet containing 2 g of sodium per day

Correct Answer is C

Explanation

A. Desmopressin acetate is used to treat diabetes insipidus, not SIADH. In SIADH, there is excessive antidiuretic hormone causing fluid retention and dilutional hyponatremia, so this medication would not be appropriate.
B. Maintaining an IV infusion of 0.45% sodium chloride is not appropriate for SIADH, as this solution can further dilute sodium levels. Treatment usually involves hypertonic saline or fluid restriction.
C. Restricting fluid intake is a key management strategy for SIADH to address the fluid overload and help correct the low sodium levels. This action directly targets the root cause of the hyponatremia by reducing fluid intake.
D. Providing a diet with 2 g of sodium per day may not be sufficient or appropriate for treating SIADH-related hyponatremia. Fluid restriction is more critical in managing this condition.

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A nurse in an emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a 55-year-old client who is 2 hours postoperative after having a total abdominal hysterectomy. Exhibits Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing dropdown,dropdownand dropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"E"}

Explanation

A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) and a sodium level of 123 mEq/L (nl. 135-145 mEq/L). Which of the following prescriptions should the nurse anticipate?

Correct Answer is C

Explanation

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