A patient is experiencing anaphylaxis after receiving an antibiotic. Which interventions should the nurse prioritize to address this condition?
(Select All that Apply.)
Administer epinephrine intramuscularly
Start intravenous access for fluid resuscitation.
Provide supplemental oxygen to the patient.
Administer corticosteroids immediately.
Place the patient in a supine position with legs elevated.
Administer oral antihistamines.
Ensure the patient has a patent airway.
Encourage oral fluid intake to counteract hypotension.
Monitor the patient's skin for rashes.
Correct Answer : A,B,C,G
A. Administering epinephrine intramuscularly is the first-line treatment for anaphylaxis, as it counteracts the effects of histamine and reduces swelling.
B. Starting intravenous access allows for fluid resuscitation and the administration of medications like epinephrine or corticosteroids.
C. Providing supplemental oxygen is necessary to support the patient's breathing and improve oxygenation during an anaphylactic reaction.
D. Corticosteroids may be used later to reduce inflammation, but they are not first-line treatments for anaphylaxis.
E. Placing the patient in a supine position with legs elevated may be helpful for circulation, but it is not the priority over administering epinephrine.
F. Oral antihistamines are not effective in the acute management of anaphylaxis, which requires immediate action.
G. Ensuring the patient's airway is patent is the top priority, as airway compromise can occur rapidly during anaphylaxis.
H. Encouraging oral fluid intake is not appropriate in this emergency situation, as intravenous fluids are needed.
I. Monitoring the patient's skin for rashes is important but secondary to managing the airway and circulation.
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Related Questions
Correct Answer is D
Explanation
A. Hyperactive bowel sounds are typically seen with diarrhea but are not a sign of hypokalemia.
B. Cerebral edema can occur with severe electrolyte imbalances, but it is not specifically related to hypokalemia caused by diarrhea.
C. Hypertension is not a typical symptom of hypokalemia; rather, hypokalemia often leads to low blood pressure.
D. Muscle weakness is a classic sign of hypokalemia because potassium is essential for proper muscle function, and low levels can impair contraction.
Correct Answer is D
Explanation
A. Documenting the seizure activity is important but should be done after addressing immediate needs.
B. Checking the patient's vital signs is important but is secondary to positioning the patient safely to prevent aspiration.
C. Administering oral antiepileptic medication is necessary but not the first action following a tonic- clonic seizure.
D. Placing the patient in a side-lying position immediately after the seizure ensures that the airway remains open and reduces the risk of aspiration.
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