A nurse is providing care to a client who exhibits wheezing after receiving an antibiotic. While planning interventions, the nurse prioritizes which assessment finding?

Abdominal cramping

Report of anxiety

Severe pruritus

Blood pressure 82/50 mmHg

Answer and Explanation

The Correct Answer is D

A. Abdominal cramping may occur during a systemic allergic reaction due to smooth muscle contraction in the gastrointestinal tract, but it is not a life-threatening finding. While uncomfortable for the client, it does not compromise the fundamental pillars of survival, which are the airway, breathing, and circulation. The nurse should note this symptom as part of the total clinical picture while focusing on more critical hemodynamic parameters.

B. A report of anxiety or a "sense of impending doom" is a common psychological symptom during anaphylaxis as the body experiences a massive sympathetic surge and hypoxia. While anxiety should be addressed with a calm nursing presence and appropriate intervention, it is a subjective symptom rather than an objective indicator of physiological collapse. The nurse must prioritize objective data that demonstrates impaired perfusion to ensure the client's physical stability.

C. Severe pruritus, or itching, is a distressing integumentary symptom caused by histamine release, but it does not pose an immediate threat to the client's life. Itching often precedes more severe symptoms but does not lead to the rapid decline associated with respiratory or cardiovascular failure. The nurse must look beyond the skin surface to identify findings that indicate the client is entering a state of anaphylactic shock.

D. A blood pressure of 82/50 mmHg is the priority finding because it indicates profound hypotension and the onset of distributive shock. Combined with the report of wheezing, this suggests the client is experiencing a full anaphylactic reaction where vasodilation and bronchoconstriction are occurring simultaneously. Immediate administration of epinephrine is required to cause vasoconstriction and raise the blood pressure, ensuring that vital organs continue to receive adequate oxygenated blood.

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Correct Answer is C

Explanation

A. Gown: A moisture-resistant gown is an essential component of contact precautions to prevent the transmission of epidemiologically significant pathogens via direct or indirect contact with the client or environmental surfaces. During tracheostomy care, there is a high risk of being sprayed by secretions, making the gown a mandatory barrier.

B. Goggles: Protective eyewear or goggles are indicated during aerosol-generating procedures, such as tracheostomy care and suctioning, to protect the mucous membranes of the eyes from splashes of respiratory secretions. While not specifically required for "contact" precautions alone, they are necessary for the specific task being performed to ensure the safety of the healthcare worker.

C. N-95 Mask: The precepting nurse must intervene because an N-95 respirator is specifically reserved for airborne precautions, such as in cases of tuberculosis, rubeola, or varicella, to filter out small-particle aerosols. Tracheostomy care and suctioning under contact precautions typically require a standard surgical mask to protect against droplets, but an N-95 is unnecessary and represents an inappropriate use of specialized resources. Using a higher level of respiratory protection than indicated does not align with established hospital infection control protocols.

D. Gloves: Clean, non-sterile gloves are the primary requirement for contact precautions and are used whenever there is potential contact with blood, body fluids, or contaminated surfaces. For tracheostomy care, the nurse may use sterile gloves for the actual procedure, but applying gloves to enter the room is fundamentally correct. Since the nurse is preparing to provide care involving bodily secretions, the use of gloves is an expected and required action that does not warrant intervention.

A. High-sodium diet B. Recent surgery C. Hormone replacement therapy D. Impaired mobility E. Cigarette smoking F. Warfarin therapy

Correct Answer is ["B","C","D","E"]

Explanation

A.A high-sodium diet is associated with hypertension and fluid retention but is not a direct independent risk factor for the formation of venous thromboembolism (VTE). While it impacts cardiovascular health, it does not fulfill any of the criteria of Virchow's Triad (venous stasis, endothelial injury, or hypercoagulability). Therefore, dietary sodium intake is not a primary assessment focus for determining immediate VTE risk.

B.Recent surgery is a major risk factor for thromboembolism due to the combination of vessel wall injury during the procedure and the resulting immobility during recovery. Surgical trauma triggers the systemic coagulation cascade as part of the healing process, which can lead to inappropriate clot formation. This fulfills the endothelial injury component of Virchow's Triad, significantly increasing the patient's clinical risk profile.

C.Hormone replacement therapy (HRT), specifically involving estrogen, increases the risk of thromboembolism by promoting a hypercoagulable state. Estrogen alters the levels of various clotting factors in the blood, making the patient more susceptible to deep vein thrombosis and pulmonary embolism. This is a critical factor the nurse must consider when reviewing the medical history of a client with suspected VTE.

D.Impaired mobility, such as bed rest or paralysis, leads to venous stasis, where blood pools in the lower extremities due to the lack of skeletal muscle pump activity. This stagnation allows clotting factors to accumulate and initiate the formation of a thrombus. It is one of the most common risk factors encountered in the hospital setting, necessitating the use of sequential compression devices and early ambulation.

E.Cigarette smoking contributes to thromboembolism by causing chronic endothelial damage and increasing blood viscosity and platelet aggregation. The toxins in tobacco smoke promote a pro-thrombotic environment throughout the vascular system, significantly elevating the risk of both arterial and venous clots. Smoking cessation is a primary educational intervention for reducing the risk of life-threatening cardiovascular and pulmonary events.

F.Warfarin therapy is an anticoagulant treatment used specifically to prevent and treat thromboembolism. Rather than increasing risk, it decreases the blood's ability to clot by interfering with vitamin K-dependent clotting factors. A patient on therapeutic levels of warfarin has a significantly lower risk of developing a new VTE compared to a patient who is not receiving anticoagulation.

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A nurse is providing care to a client who exhibits wheezing after receiving an antibiotic. While planning interventions, the nurse prioritizes which assessment finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A precepting nurse is observing a new graduate nurse prepare to enter a client's room to provide tracheostomy care and suctioning. The client is on contact precautions. The nurse intervenes when the new graduate nurse applies which piece of personal protective equipment (PPE)?

Correct Answer is C

Explanation

The nurse is caring for several clients on a medical unit, and recognizes that which of the following factors increases a client's risk for thromboembolism? Select all that apply

Correct Answer is ["B","C","D","E"]

Explanation

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