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 A

Explanation

A. Cardiac tamponade is a condition where fluid accumulates in the pericardial space, exerting pressure on the heart and impeding its ability to pump effectively, leading to obstructive shock.
B. Third spacing refers to fluid accumulation in the interstitial spaces but is not a specific diagnosis of obstructive shock.
C. A ruptured aneurysm may lead to hypovolemic shock due to blood loss rather than obstructive shock, which is characterized by physical obstruction to blood flow.
D. Cardiomyopathy is a disease of the heart muscle that affects its ability to pump blood, leading to cardiogenic shock, not obstructive shock.

A. Administer hypertonic saline and restrict water intake B. Start fluid restriction and administer a loop diuretic C. Administer isotonic saline and encourage oral fluid intake D. Increase oral sodium intake and administer an antiemetic

Correct Answer is A

Explanation

A. Administering hypertonic saline (3% NaCl) is appropriate for treating severe hyponatremia, as it helps to raise sodium levels safely. Restricting water intake is also necessary to prevent further dilution of sodium.
B. Fluid restriction with a loop diuretic may not be effective in this scenario and can worsen the hyponatremia by causing further fluid loss without addressing the sodium levels.
C. Isotonic saline is not indicated for correcting severe hyponatremia, and encouraging oral fluid intake could exacerbate the condition.
D. Increasing oral sodium intake is not sufficient for immediate correction of severe hyponatremia and does not address the acute nature of the client’s symptoms.

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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

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