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

Auscultate for wheezing.

Assess the client’s level of consciousness.

Administer epinephrine.

Monitor for hypotension.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Auscultating for wheezing is important but not the first action. The priority is to administer epinephrine to counteract the severe allergic reaction.

Choice B rationale

Assessing the client’s level of consciousness is important but not the first action. Administering epinephrine takes precedence to stabilize the client’s condition.

Choice C rationale

Administering epinephrine is the first action. It is crucial to counteract the severe allergic reaction and prevent further complications.

Choice D rationale

Monitoring for hypotension is important but not the first action. Administering epinephrine is the priority to stabilize the client’s condition.

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Correct Answer is B

Explanation

Choice B rationale

The FLACC scale (Face, Legs, Activity, Cry, Consolability) is specifically designed for assessing pain in infants and young children who are unable to communicate their pain verbally.

Choice A rationale

The Visual Analog Scale is used for older children and adults who can understand and communicate their pain level.

Choice C rationale

The Oucher scale is used for children aged 3 to 12 years and involves matching facial expressions to a pain level.

Choice D rationale

The Faces scale is used for children aged 3 years and older who can point to a face that best represents their pain level.

A. Apply a non-pressure patch to the affected eye. B. Clean the eye from inner to outer canthus. C. Notify the surgeon. D. Instill an antibiotic solution in both eyes.

Correct Answer is C

Explanation

Choice A rationale

Applying a non-pressure patch to the affected eye can help protect the eye from further irritation or injury. However, it does not address the underlying issue of purulent drainage, which could indicate an infection that requires immediate medical attention.

Choice B rationale

Cleaning the eye from inner to outer canthus is a standard practice to prevent the spread of infection. However, in this case, the presence of purulent drainage suggests a possible infection that needs to be evaluated by a surgeon.

Choice C rationale

Notifying the surgeon is the priority action because purulent drainage from the eye can indicate a serious infection or complication following surgery. Immediate medical evaluation and intervention are necessary to prevent further complications and ensure proper treatment.

Choice D rationale

Instilling an antibiotic solution in both eyes may be part of the treatment plan for an infection. However, the nurse should first notify the surgeon to get appropriate orders and ensure that the correct antibiotic and treatment plan are followed.

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

Nursing Test Bank

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