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. This client has no respirations and delayed capillary refill, suggesting a critical lack of oxygenation. However, the lack of respirations with no success in repositioning the airway indicates that this client may be beyond resuscitation. The priority would be to address clients who are still viable for treatment.

B. This client is at risk for respiratory distress due to the sucking chest wound and requires immediate attention. The wound could lead to a pneumothorax, which compromises oxygenation. The respirations of 38/min indicate distress, but the capillary refill of <2 seconds suggests better perfusion making this client a priority for care.

C. While this client requires treatment for the dislocated shoulder, their vital signs (normal respiratory rate and good capillary refill) indicate that this client is stable. This makes them a lower priority than the unconscious client with the sucking chest wound.

D. This client is experiencing shortness of breath and has a respiratory rate of 24/min, but their capillary refill is normal. Although this client needs further assessment, they are stable compared to the unconscious client with the sucking chest wound.

A. Burr hole B. A coup, contrecoup injury C. Concussion D. Hematoma

Correct Answer is B

Explanation

A. Burr hole: A burr hole is a small hole drilled into the skull to relieve pressure or drain fluid, but it is not a type of brain injury. It is a medical intervention, not an injury description like coup, contrecoup.

B. A coup, contrecoup injury: A coup, contrecoup injury occurs when the brain is bruised in two areas: at the site of impact (coup) and on the opposite side of the brain (contrecoup). This is consistent with the patient's CT and MRI findings of bruising in both the anterior and posterior parts of the brain.

C. Concussion: A concussion is a mild traumatic brain injury that typically causes temporary confusion or loss of consciousness. However, a concussion does not typically present with visible bruising on both the anterior and posterior areas of the brain.

D. Hematoma: A hematoma refers to a collection of blood outside of blood vessels, which can occur in the brain after trauma. While a hematoma may result from brain bruising, it is not a description of the injury pattern like coup, contrecoup.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is the triage officer in the emergency department when four clients arrive following a factory explosion. Which of the following clients should the nurse care for first?

Correct Answer is B

Explanation

Your patient is currently unconscious after a bad car accident. After a CT scan and MRI are performed on the patient's head and neck, there are signs of brain bruising on both the anterior and posterior portions of the brain. This should be documented as signs of what?

Correct Answer is B

Explanation

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