A nurse in an emergency department is caring for an adolescent who is experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse?
Elevate the head of the child's bed.
Administer IM epinephrine to the child.
Determine the allergen that caused the child's reaction
Insert a large bore IV catheter for the child.
The Correct Answer is B
A. Elevating the head of the bed may be useful after airway management but is not the priority in anaphylaxis.
B. Administering IM epinephrine is the priority action in anaphylaxis, as it works rapidly to reverse the symptoms by constricting blood vessels, relaxing smooth muscles, and improving breathing.
C. Determining the allergen is important for future prevention, but the immediate priority is treating the reaction.
D. While establishing IV access is important for fluid resuscitation, it is not the priority over administering epinephrine in anaphylaxis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Typically, infants are kept NPO for 1-2 hours before a lumbar puncture, not 6 hours.
B. Holding the infant’s chin to the chest and knees to the abdomen during the lumbar puncture is the correct positioning. This position opens the intervertebral spaces and allows for easier access to the spinal cord.
C. Eutectic mixture of lidocaine and prilocaine (EMLA) cream should be applied 60 minutes before the procedure for effective local anesthesia, not 15 minutes.
D. After the procedure, the infant should be placed flat to avoid pressure on the lumbar area, not in an infant seat. The infant should be positioned on their back or side to prevent strain.
Correct Answer is A
Explanation
A. A normal urinary output in infants is approximately 1-2 mL/kg/hr. An output of 2 mL/kg/hr would indicate that the fluid imbalance is being corrected.
B. An output of 7.5 mL/kg/hr is excessive and may indicate overhydration or other complications.
C. An output of 0.5 mL/kg/hr is too low and suggests that the fluid imbalance is not yet corrected.
D. An output of 15 mL/kg/hr is too high and could indicate a possible issue such as overhydration.
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