A nurse in an urgent care facility is collecting data from a client who was stung by a wasp. Which of the following findings indicates the client is experiencing anaphylaxis?

Bilateral tinnitus

Difficulty swallowing

Hypertension

Petechial rash on the abdomen

Answer and Explanation

The Correct Answer is B

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Correct Answer is A

Explanation

The correct answer is choice A, Perform suctioning. Restlessness and crackles in the lungs may indicate respiratory distress or airway obstruction, which may be due to mucus or secretions blocking the tracheostomy tube. Performing suctioning helps clear the airway of secretions, which will improve the client's breathing. Choice B is incorrect because instilling saline into the tubing is not a common intervention for managing restlessness and crackles. Choice C is incorrect because checking the cuff pressure is not related to managing restlessness and crackles. Choice D is incorrect because increasing humidification is not a common intervention for managing restlessness and crackles.

Other choices:

Instill saline into the tubing: Instilling saline into the tubing is not a common intervention for managing restlessness and crackles.

Check the cuff pressure: Checking the cuff pressure is not related to managing restlessness and crackles.

Increase the humidification: Increasing humidification is not a common intervention for managing restlessness and crackles.

A. Review the signs of anaphylaxis with the client. B. Instruct the client to store the injector at room temperature. C. Inform the client to seek medical attention following administration of the injection. D. Have the client perform a return demonstration of the equipment.

Correct Answer is C

Explanation

The correct answer is c. Inform the client to seek medical attention following administration of the injection.

Choice A reason: Reviewing the signs of anaphylaxis with the client is important, but it’s not the priority. The client must first know what to do in case of an emergency.

Choice B reason: Instructing the client to store the injector at room temperature is a part of the storage instructions, but it’s not the immediate action to take during an anaphylactic reaction.

Choice C reason: This is the priority because anaphylaxis is a potentially life-threatening condition and even after administering epinephrine, it’s crucial to seek immediate medical attention.

Choice D reason: Having the client perform a return demonstration of the equipment is a good teaching method, but it’s not the immediate action to take when an anaphylactic reaction occurs.

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A nurse in an urgent care facility is collecting data from a client who was stung by a wasp. Which of the following findings indicates the client is experiencing anaphylaxis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a tracheostomy tube. Upon data collection, the nurse observes the client is restless and hears crackles in the lungs. Which of the following interventions should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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