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","D","E"]
Explanation
A. Sickled cells are rigid, not flexible, making it harder for them to pass through small vessels.
B. Sickled red blood cells are crescent or "c" shaped and have an increased tendency to clump together, which obstructs blood flow.
C. Sickled cells have a short lifespan, so they do not circulate longer than healthy cells.
D. Sickled cells are rigid, making it difficult for them to pass through small blood vessels, leading to blockages and reduced oxygen delivery.
E. Sickled red blood cells have a shorter lifespan (about 10-20 days compared to the normal 120 days), leading to anemia and a decreased number of circulating red blood cells.
Correct Answer is A
Explanation
A. Decreased attention span is a common manifestation of increased intracranial pressure, as pressure on the brain can affect cognitive function.
B. Hyperactivity is not typically associated with increased intracranial pressure. It would be more common for the child to exhibit lethargy or irritability.
C. Tachycardia is not a primary symptom of increased intracranial pressure. Typically, bradycardia (slow heart rate) is seen in cases of severe intracranial pressure.
D. Hypotension is not usually associated with increased intracranial pressure. In fact, increased intracranial pressure often leads to elevated blood pressure and a widening pulse pressure.
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