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 C

Explanation

The correct answer is c. Apply a moist saline dressing to the area.

Choice A reason: Obtaining a set of vital signs is important, but it is not the immediate priority in this situation. The vital signs will not address the protruding organs directly.

Choice B reason: Flexing the client’s knees and hips may provide comfort but does not directly address the issue of the open incision and protruding organs.

Choice C reason: Applying a moist saline dressing to the area is the correct action. It helps to protect the protruding organs by keeping them moist and reduces the risk of organ damage or infection. This is the priority action to keep the organs moist and reduce the risk of tissue damage until surgical repair can be done.

Choice D reason: Elevating the head of the client’s bed 20° may be part of the overall care plan, but it is not the immediate priority when dealing with protruding organs from an open abdominal incision.

A. Take iron supplements between meals for maximum absorption. B. Reduce gastric distress by taking iron supplements with an antacid. C. Check for orange-colored stools after 4 days of treatment. D. Mix iron supplements with milk to prevent staining of the teeth.

Correct Answer is A

Explanation

The correct answer is choice A. The nurse should instruct the client to take iron supplements between meals for maximum absorption. Choice B is incorrect because antacids can decrease the absorption of iron. Choice C is incorrect because orange-colored stools may occur after the first dose of iron. Choice D is incorrect because milk can also decrease the absorption of iron. Choice B is not correct because antacids can decrease the absorption of iron. Choice C is not correct because orange-colored stools may occur after the first dose of iron. Choice D is not correct because milk can also decrease the absorption of iron.

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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 is 4 hr postoperative following an abdominal surgery and notes that the client's abdominal incision is open and the internal organs are protruding. After contacting the rapid response team, which of the following actions should the nurse take next?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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