A nurse suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following is the priority intervention by the nurse?
Prepare to administer epinephrine.
Administer oxygen.
Insert an IV line.
Check the client's respiratory status.
The Correct Answer is D
A. Prepare to administer epinephrine:
While this is a critical intervention, it comes after confirming respiratory compromise or other signs of anaphylaxis.
B. Administer oxygen:
Oxygen is helpful once airway and breathing are assessed, but not the very first priority.
C. Insert an IV line:
IV access is necessary for treatment but should be done after assessing the client's immediate status.
D. Check the client's respiratory status:
According to ABCs (Airway, Breathing, Circulation), the first priority is to assess airway and breathing to determine the severity of the anaphylactic reaction and guide emergency interventions.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Describe the environment to the client – While important, this is not the priority. Ensuring a safe environment first prevents accidents before familiarizing the client with their surroundings.
B. Instruct the client to use the call light when preparing to ambulate – This promotes safety but does not directly prevent falls or hazards from clutter.
C. Encourage the client to feel the walls with her hands – This might help with orientation, but it is not the safest approach to mobility and may lead to unintended accidents.
D. Remove clutter from the client's room: Safety is the priority when assisting a client with vision loss. Removing clutter minimizes the risk of falls and injuries, ensuring a safer environment. A well-organized space allows the client to navigate more confidently
Correct Answer is D
Explanation
A. Prepare to administer epinephrine:
While this is a critical intervention, it comes after confirming respiratory compromise or other signs of anaphylaxis.
B. Administer oxygen:
Oxygen is helpful once airway and breathing are assessed, but not the very first priority.
C. Insert an IV line:
IV access is necessary for treatment but should be done after assessing the client's immediate status.
D. Check the client's respiratory status:
According to ABCs (Airway, Breathing, Circulation), the first priority is to assess airway and breathing to determine the severity of the anaphylactic reaction and guide emergency interventions.
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