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?

Administer methylprednisolone.

Administer oxygen.

Administer epinephrine.

Administer a nebulized bronchodilator.

Answer and Explanation

The Correct Answer is C

A. Methylprednisolone is a corticosteroid that can help reduce inflammation. While it may be beneficial in some cases of allergic reactions, it is not the first-line treatment for severe
anaphylaxis. In this situation, the priority is to address the immediate symptoms and stabilize the child's condition.

B. Administering oxygen is an important intervention, especially if the child is experiencing respiratory distress. However, in the case of severe anaphylaxis, administering epinephrine is the highest priority as it addresses multiple aspects of the reaction, including airway constriction,
low blood pressure, and hives.

C. This is the correct action. Epinephrine is the first-line treatment for anaphylaxis. It works rapidly to improve breathing, increase blood pressure, and reduce allergic symptoms. It is considered the most critical intervention in this situation.

D. Nebulized bronchodilators can be beneficial for respiratory distress, but they are not the first-line treatment for severe anaphylaxis. Epinephrine is more effective in rapidly reversing the
allergic reaction and stabilizing the child's condition. It addresses a broader range of symptoms in anaphylaxis compared to a bronchodilator.

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Correct Answer is D

Explanation

- A: Tighten the screws on the halo device one-quarter turn every 48 hr.
- Rationale: This action is incorrect because the screws on a halo device should not be adjusted by the nurse. The screws are typically set and secured by a healthcare provider, and any adjustments can compromise the integrity of the device and the stability of the cervical spine.

- B: Assess the pin sites for infection once every other day.
- Rationale: While it is important to monitor the pin sites for signs of infection, doing so once every other day may not be sufficient. Pin sites should be assessed at least once per shift to ensure early detection and management of any potential infection.

- C: Encourage flexion and extension of the neck.
- Rationale: This action is contraindicated for a client with a halo vest. The purpose of the halo vest is to immobilize the cervical spine to promote healing. Encouraging neck movement could cause further injury or delay healing.

- D: Reposition the client using a turning sheet.
- Rationale: This is the correct action. Using a turning sheet helps to reposition the client safely and effectively without exerting unnecessary pressure on the cervical spine. It also aids in preventing pressure ulcers and promotes comfort for the client.

A. Nightmares B. Hyperactivity C. Pruritus D. Diplopia

Correct Answer is D

Explanation

A. Nightmares are common in children and may not be directly related to the brain tumor. While they should be addressed, they are not the priority in this case.

B. Hyperactivity can be a normal behavior in preschoolers. It may or may not be related to the brain tumor. Other symptoms should take precedence.

C. Pruritus (itching) is a common symptom that can have various causes, and it may not be directly related to the brain tumor. It should be addressed but is not the priority in this case.

D. Correct. Diplopia (double vision) can be a neurological symptom associated with increased

intracranial pressure or other complications related to a brain tumor. It is important to report this finding promptly to the provider for further evaluation and intervention.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative following placement of a halo vest to manage a cervical vertebral fracture. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a preschooler who has a brain tumor. Which of the following findings is the priority for the nurse to report to the provider?

Correct Answer is D

Explanation

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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?

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