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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
A. Oliguria, or decreased urine output, is a common finding in hypovolemia due to reduced renal perfusion and decreased blood flow to the kidneys.
B. Hypertension is unlikely in hypovolemia; instead, clients typically exhibit hypotension due to decreased circulating blood volume.
C. Bradycardia is not a typical finding in hypovolemia; instead, tachycardia is more commonly observed as the body compensates for reduced blood volume.
D. Peripheral edema is associated with fluid overload rather than hypovolemia, as a decrease in blood volume usually leads to less fluid accumulation in the tissues.
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