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 B

Explanation

A. Respiratory alkalosis is characterized by a high pH and low PaCO2, which is not evident in this scenario where the pH is low and PaCO2 is elevated.
B. The low pH of 7.3 indicates acidemia, and the elevated PaCO2 of 50 mm Hg suggests respiratory acidosis, where the body is retaining carbon dioxide, leading to an increase in acidity.
C. Metabolic acidosis would present with a low pH and a normal or decreased PaCO2, which is not the case here since the PaCO2 is elevated.
D. Metabolic alkalosis would show a high pH and elevated HCO3 levels, which is not consistent with the given ABG results.

A. Anuria B. Hypotension C. Increased respiratory rate D. Decreased level of consciousness

Correct Answer is C

Explanation

A. Anuria, or the absence of urine output, indicates significant renal impairment and is a later sign of shock.
B. Hypotension is a classic sign of shock but occurs after compensatory mechanisms have failed.
C. An increased respiratory rate is often one of the earliest indicators of shock, as the body attempts to compensate for reduced oxygenation and tissue perfusion by increasing respiratory effort.
D. A decreased level of consciousness can occur with prolonged shock but typically presents after other compensatory mechanisms have been overwhelmed.

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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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