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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Platelets 75,000/mm3: A platelet count of 75,000/mm³ is below the normal range (150,000-450,000/mm³). In DIC platelets are consumed due to excessive clotting, and a low platelet count is a significant finding. This should be reported to the provider, as it may indicate worsening or active DIC.
B. Glucose 95 mg/dL: A glucose level of 95 mg/dL is within the normal range (70-100 mg/dL). This value does not require immediate attention and is not related to DIC.
C. Hemoglobin 12.8 g/dL: Hemoglobin levels of 12.8 g/dL are within the normal range (12-16 g/dL for females, 14-18 g/dL for males). There is no indication of anemia or blood loss in this value.
D. Red blood cells 4.9 million/mm³: A red blood cell count of 4.9 million/mm³ is within the normal range (4.5-5.9 million/mm³ for males, 4.1-5.1 million/mm³ for females). This value does not indicate a concern related to DIC.
Correct Answer is B
Explanation
C. Ease the visitor to the floor: This is the first priority to prevent injury. Safely guiding the person to the ground helps reduce the risk of trauma from falling.
A. Maintain a patent airway: Once on the ground, the nurse should position the person (ideally on their side) to promote airway patency and prevent aspiration.
D. Obtain vital signs: After the seizure ends, assessing vital signs helps evaluate postictal status and detect any complications such as hypoxia or hypotension.
B. Record the seizure activity observed: Documentation of the seizure’s onset, duration, and characteristics is important, but it comes after safety and assessment priorities are addressed.
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