A nurse is assessing a client after administering a dose of losartan. The client has a hoarse voice, and swollen lips and tongue. In which order should the nurse take the following actions?

Assess the client's airway.

Call the emergency response team.

Apply high-flow oxygen.

Initiate IV access.

Administer IV epinephrine.

Administer IV antihistamines.

Answer and Explanation

The Correct Answer is A,B,C,D,E,F

1. Assessing the client's airway is the priority to determine if there is any obstruction or compromise due to swelling.

2. Calling the emergency response team ensures that additional medical help is on the way if the situation worsens.

3. Applying high-flow oxygen is critical to address potential hypoxia from airway swelling.

4. Initiating IV access is necessary for administering medications.

5. Administering IV epinephrine is essential to counteract severe allergic reactions, such as angioedema.

6. Administering IV antihistamines can help alleviate symptoms but is secondary to the immediate interventions for airway management and epinephrine administration.

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Correct Answer is C

Explanation

A. Obstructive shock occurs when blood flow is physically obstructed, such as in cases of pulmonary embolism or cardiac tamponade, which is not indicated here as the cause is blood loss.
B. Septic shock is related to infection and systemic inflammatory response, not directly caused by blood loss.
C. Hypovolemic shock is caused by a significant loss of blood volume, leading to decreased blood pressure, which directly relates to the client losing 800 mL of blood during surgery. This condition results in inadequate perfusion and oxygen delivery to tissues.
D. Neurogenic shock results from spinal cord injuries leading to vasodilation and bradycardia, which is not applicable to this scenario.

A. IV antibiotics B. Urinalysis C. Chest x-ray D. Chest tube placement E. Admit to inpatient F. Airborne precautions G. Draw an STI lab panel H. Complete blood count

Correct Answer is ["A","C","E","H"]

Explanation

The nurse anticipates the following orders from the provider based on the suspected diagnosis:

A. IV antibiotics: To treat the suspected infection.
C. Chest x-ray: To assess the lungs for signs of infection, such as pneumonia.
E. Admit to inpatient: The client's worsening condition and need for aggressive treatment warrant hospitalization.
H. Complete blood count: To assess the client's overall health status and identify any abnormalities, such as anemia or infection.

Rationale:

B. Urinalysis: While a urinalysis can be helpful in assessing for urinary tract infections, it is not a priority in this case.
D. Chest tube placement: This is not indicated unless the client develops a pleural effusion or pneumothorax.
F. Airborne precautions: This is not necessary for the client's current condition.
G. Draw an STI lab panel: While this may be relevant for the client's overall health, it is not a priority at this time, especially given the client's acute presentation.

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A nurse is assessing a client after administering a dose of losartan. The client has a hoarse voice, and swollen lips and tongue. In which order should the nurse take the following actions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Explanation

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