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 D

Explanation

Choice A rationale

Sound lateralizing to the right ear during the Rinne test does not indicate conductive hearing loss in the left ear. This result suggests that the right ear may have better hearing or that there is an issue with the left ear, but it does not specifically diagnose conductive hearing loss.

Choice B rationale

Sound lateralizing to the left ear during the Rinne test indicates that the left ear is perceiving the sound better, which could be due to conductive hearing loss in the left ear. However, this option does not provide a definitive result for conductive hearing loss.

Choice C rationale

Air conduction being greater than bone conduction in the left ear is a normal finding and does not indicate conductive hearing loss. In conductive hearing loss, bone conduction is typically better than air conduction.

Choice D rationale

Air conduction being less than bone conduction in the left ear is indicative of conductive hearing loss. This result means that the sound is being conducted through the bones of the skull more effectively than through the air, which is a hallmark of conductive hearing loss.

A. Speak loudly and into the client’s good ear. B. Use sign language when communicating with the client. C. Sit by the client’s side and speak very slowly. D. Speak directly to the client in a normal, clear voice.

Correct Answer is D

Explanation

Choice A rationale

Speaking loudly and into the client’s good ear is not recommended. Loud speech can be distorted and uncomfortable for individuals with presbycusis.

Choice B rationale

Using sign language is not necessary unless the client is proficient in it. Most clients with presbycusis benefit more from clear verbal communication.

Choice C rationale

Sitting by the client’s side and speaking very slowly is not as effective as speaking directly to the client in a normal, clear voice.

Choice D rationale

Speaking directly to the client in a normal, clear voice is recommended. This ensures that the client can read lips and understand the conversation better.

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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

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client for conductive hearing loss. When using the Rinne test, which of the following results should the nurse identify as an indication that the client has conductive hearing loss of the left ear?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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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?