A nurse is caring for a client who has a peanut allergy. The client states. "I feel like my throat is closing "Which of the following actions should the nurse take?

Deliver 2 L of oxygen via partial nonrebreather mask.

Give epinephrine intramuscularly

Administer diazepam PO.

Notify the radiology department

Answer and Explanation

The Correct Answer is B

Rationale:

A. Deliver 2 L of oxygen via partial nonrebreather mask: While oxygen can support airway function, it does not address the underlying cause of anaphylaxis. Airway closure due to an allergic reaction requires immediate pharmacologic intervention, not just oxygen delivery.

B. Give epinephrine intramuscularly: Epinephrine is the first-line treatment for anaphylaxis. It counteracts bronchoconstriction, airway edema, and hypotension by stimulating alpha and beta receptors, and should be administered immediately when signs of airway compromise are present.

C. Administer diazepam PO: Diazepam is used for anxiety or seizures, not for acute allergic reactions. It has no effect on reversing airway swelling or bronchospasm and would delay the appropriate emergency treatment needed in this situation.

D. Notify the radiology department: Contacting the radiology department is not relevant or urgent in this scenario. The client is experiencing a life-threatening reaction that requires immediate medical intervention, not communication with non-emergency services.

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Correct Answer is D

Explanation

Rationale:

A. "Go to bed at least 2 hours earlier than usual.": Going to bed earlier may increase total sleep time, but it does not directly address the cause of nighttime awakening—frequent urination. Earlier bedtime alone is unlikely to improve the client’s quality of sleep.

B. "Have a snack before bedtime.": A bedtime snack may help prevent nausea or maintain blood sugar levels but does not reduce nighttime urinary frequency. In some cases, it might lead to increased fluid intake, potentially worsening nocturia.

C. "Drink a cup of chamomile tea at bedtime.": While chamomile may promote relaxation, it is also a fluid, which can increase bladder activity during the night. Encouraging tea before bed may worsen the client's urinary frequency and sleep disruption.

D. "Take regular rest periods during the day.": Taking rest periods throughout the day can help reduce overall fatigue and minimize sleep disruption caused by nocturia. Resting during the day compensates for nighttime interruptions and supports maternal well-being in early pregnancy.

A. "The client can revoke consent even after the procedure has begun." B. "The nurse is responsible for obtaining informed consent.” C. "Consent must be obtained from a family member if a client has a mental illness." D. "The charge nurse will explain the risks of the procedure to the client.”

Correct Answer is A

Explanation

Rationale:

A. "The client can revoke consent even after the procedure has begun.": Clients have the legal right to withdraw consent at any time, including during a procedure. Respecting this autonomy is essential, and healthcare providers must stop the procedure if the client revokes consent.

B. "The nurse is responsible for obtaining informed consent.": Obtaining informed consent is the responsibility of the provider performing the procedure, who must ensure the client understands the risks, benefits, and alternatives. Nurses typically witness and verify the signature but do not obtain consent.

C. "Consent must be obtained from a family member if a client has a mental illness.": Consent depends on the client’s decision-making capacity, not solely on the presence of mental illness. If the client is competent, they can provide consent; if not, a legally authorized representative may be involved.

D. "The charge nurse will explain the risks of the procedure to the client.": Explaining procedure risks is the responsibility of the healthcare provider performing the procedure, not the charge nurse. This ensures that the explanation is accurate and comprehensive.

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