A nurse in the emergency department is caring for a school-age child who has developed respiratory stridor, wheezing and urticaria after receiving an IV medication.
Which of the following actions should the nurse take first?
swer and explanation
Administer oxygen
Administer a nebulized bronchodilator
Administer epinephrine
The Correct Answer is D
Choice A rationale
Administering methylprednisolone, a corticosteroid, can help reduce inflammation. However, it is not the first-line treatment for severe anaphylaxis.
Choice B rationale
Administering oxygen can help improve the child’s oxygenation, but it is not the first action the nurse should take in this situation.
Choice C rationale
Administering a nebulized bronchodilator can help relieve wheezing, but it is not the first action the nurse should take in this situation.
Choice D rationale
Administering epinephrine is the first-line treatment for anaphylaxis. It works quickly to improve breathing, stimulate the heart, raise a dropping blood pressure, and reduce swelling of the face, lips, and throat.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Prolonged headache is not typically identified as a common trigger for seizures. While headaches can be associated with certain types of seizures, they are not generally considered a trigger for seizure activity.
Choice B rationale
Decreased temperature, or hypothermia, is not typically identified as a common trigger for seizures. In fact, fever or increased body temperature is more commonly associated with triggering seizures, particularly in children.
Choice C rationale
Lack of sleep is a well-recognized trigger for seizures. Sleep deprivation can lead to increased seizure frequency in individuals with epilepsy. Ensuring adequate sleep is an important part of managing seizure disorders.
Choice D rationale
Exposure to second-hand smoke is not typically identified as a common trigger for seizures. While it is generally harmful to health, it is not specifically associated with an increased risk of seizures.
Correct Answer is B
Explanation
Choice A rationale
Aspartame is a low-calorie sweetener used in place of sugar. However, it is not recommended for individuals with phenylketonuria (PKU) because it contains phenylalanine, an amino acid that individuals with PKU cannot metabolize properly.
Choice B rationale
Individuals with PKU are advised to avoid foods containing milk products. This is because milk and other
dairy products contain phenylalanine, which individuals with PKU cannot metabolize properly. Instead, they are advised to consume a diet low in protein and supplemented with a phenylalanine-free medical formula.
Choice C rationale
Increasing protein consumption is not recommended for individuals with PKU. This is because protein-rich foods often contain phenylalanine, an amino acid that individuals with PKU cannot metabolize properly.
Instead, they are advised to consume a diet low in protein and supplemented with a phenylalanine-free medical formula.
Choice D rationale
Limiting foods high in iron is not specifically related to the dietary management of PKU. Individuals with PKU primarily need to avoid foods high in phenylalanine.
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