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

Answer and Explanation

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.

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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. Respiratory alkalosis B. Respiratory acidosis C. Metabolic acidosis D. Metabolic alkalosis

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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