A nurse in an emergency department is caring for a client who just walked in with respiratory distress and possible reaction following a dose of newly prescribed antibiotic. Which of the following actions should the nurse take first?

Assess respiratory effort and oxygenation status

Assess the client's level of consciousness

Monitor for hypotension

Prepare to administer IV fluids

Answer and Explanation

The Correct Answer is A

A. Assess respiratory effort and oxygenation status: Ensuring the client is receiving adequate oxygen and monitoring for signs of airway compromise, such as wheezing, stridor, or difficulty breathing, is essential. This helps determine the severity of the reaction and the need for interventions such as oxygen therapy or intubation.

B. Assess the client's level of consciousness: While it’s important to assess the client's level of consciousness, respiratory assessment takes priority in cases of respiratory distress. Oxygenation is the most immediate concern.

C. Monitor for hypotension: Hypotension may occur as part of an anaphylactic reaction, but it is a secondary concern to airway management and oxygenation. Hypotension is addressed after ensuring the client’s breathing is supported and the airway is secure.

D. Prepare to administer IV fluids: IV fluids may be necessary to treat hypotension, but the first action should focus on assessing and stabilizing the client's breathing and oxygenation. After addressing the airway, IV fluids can be considered if hypotension persists.

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Correct Answer is B

Explanation

A. Position the head of the client's bed in the flat position: Flat positioning increases aspiration risk, which can lead to VAP. Elevating the head to 30-45 degrees helps reduce aspiration and is more effective in preventing VAP.

B. Rinse the client's mouth with an antimicrobial solution every 4 hr: Regular oral care with an antimicrobial solution, such as chlorhexidine, every 4 hours is a crucial. This practice helps to prevent the migration of oral pathogens into the lower respiratory tract

C. Perform hand hygiene after suctioning the client's endotracheal tube: Hand hygiene is essential, but doing it after suctioning the client's endotracheal tube is insufficient for preventing VAP. Hand hygiene should be performed before and after any client contact.

D. Turn the client every 4 hr: Turning the client every 4 hours is an important intervention for preventing skin breakdown and promoting circulation. However, it does not directly prevent VAP as comprehensive oral care or head-of-bed elevation.

A. Inspect the mouth for signs of inhalation injuries B. Administer intravenous pain medication C. Insert an indwelling urinary catheter D. Draw blood for a complete blood cell (CBC) count

Correct Answer is A

Explanation

A. Inspect the mouth for signs of inhalation injuries: The priority action for a client with burns, especially facial burns is to assess for potential inhalation injuries. Inhalation of hot gases or smoke can cause damage to the airways, leading to swelling, obstruction, and respiratory distress.

B. Administer intravenous pain medication: Pain management is important, but it is not the immediate priority. Ensuring the client’s airway is protected and that there are no life-threatening respiratory complications takes precedence over pain relief in the early stages of burn care.

C. Insert an indwelling urinary catheter: Inserting a urinary catheter is typically done for monitoring urine output in burn patients, especially if there is concern for fluid resuscitation needs. However, it is not the priority. Assessing for respiratory injury should come first.

D. Draw blood for a complete blood cell (CBC) count: While a CBC can provide useful information, such as signs of infection or anemia, it is not the priority action. The immediate priority is ensuring the airway is safe and free of inhalation injury, as respiratory compromise can lead to rapid deterioration.

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A nurse in an emergency department is caring for a client who just walked in with respiratory distress and possible reaction following a dose of newly prescribed antibiotic. Which of the following actions should the nurse take first?

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