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. Gingivitis is a form of gum disease that can occur in anyone, but it is not specifically related to low CD4-T-cell counts associated with AIDS.
B. Candidiasis, also known as oral thrush, is a fungal infection caused by Candida species. Clients with a significantly decreased CD4-T-cell count are at high risk for opportunistic infections, including candidiasis, due to their compromised immune systems.
C. Xerostomia refers to dry mouth, which can occur for various reasons but is not specifically an infectious condition linked to low CD4 counts.
D. Halitosis, or bad breath, can result from several factors, including poor oral hygiene or underlying health issues, but is not specifically linked to the immune status of a client with AIDS.
Correct Answer is A
Explanation
A. Respiratory acidosis is indicated by the low pH (7.22) and elevated PaCO2 (68 mm Hg), demonstrating that CO2 is retained due to hypoventilation (as seen with a respiratory rate of 7/min). The bicarbonate level is within normal range, suggesting no metabolic compensation is present.
B. Metabolic acidosis would be indicated by a low pH and low bicarbonate level, which is not the case here since the bicarbonate is normal at 26 mEq/L.
C. Metabolic alkalosis would present with a high pH and high HCO3, which does not match these values.
D. Respiratory alkalosis would show a high pH and low PaCO2, which is contrary to the provided ABG results.
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