A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first?
Stridor
Hypotension
Urticaria
Vomiting
The Correct Answer is A
A. Stridor is a high-pitched sound indicating upper airway obstruction and is a critical sign of anaphylaxis requiring immediate intervention to secure the airway.
B. Hypotension is a serious condition that occurs during anaphylaxis, but the priority is to address the airway obstruction first.
C. Urticaria (hives) is a common symptom of an allergic reaction but is not life-threatening and can be addressed after more severe symptoms.
D. Vomiting may occur during anaphylaxis but is not the most urgent finding when airway compromise is present.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hepatitis is a concern for individuals with HIV, but it is not specifically indicated by a low CD4-T-cell count.
B. A CD4-T-cell count of 150/mm³ indicates severe immunosuppression, making the client highly susceptible to opportunistic infections like tuberculosis, which is common in individuals with HIV.
C. While gonorrhea is a risk for sexually active individuals, it is not specifically related to the low CD4-T-cell count.
D. Chlamydia is also a sexually transmitted infection, but similar to gonorrhea, it is not directly linked to the immunocompromised state indicated by the CD4-T-cell count.
Correct Answer is C
Explanation
A. Abuse refers to the mistreatment of a patient, which does not apply to this scenario as the issue was an error rather than intentional harm.
B. Battery involves intentional and wrongful physical contact with another person; while the wrong medication is harmful, it was not an intentional act of violence.
C. Malpractice is the correct choice because it involves negligence in the professional duties of a healthcare provider, resulting in harm to a patient. The nurse failed to adhere to the standard of care by administering the incorrect medication.
D. Assault refers to the threat of harm or the act of creating fear of harm in another person, which is not applicable in this scenario since the nurse did not threaten the client.
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