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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.

Answer and Explanation

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

Explanation

A. Using sterile water is recommended for flushing the tube before and after feeding, but it is not the most critical step in preventing complications.
B. Lowering the head of the bed to 15 degrees during feeding may increase the risk of aspiration, as a higher elevation is typically recommended.
C. Changing the feeding bag and tubing every 24 hours helps prevent bacterial contamination and reduces the risk of infection.
D. Checking for residual volume before each feeding helps ensure that the stomach is empty, reducing the risk of aspiration.
E. Adding crushed medications to the enteral formula is not recommended, as it can alter the formula's absorption and cause clogging of the tube.
F. Administering the feeding in a continuous cycle over 24 hours is typically done for certain patients, but it is not essential to prevent complications in all cases.

A. "Monitor for the appearance of ecchymosis on the sides of your abdomen/pelvic areas." B. "Monitor for any increase or unintentional weight gain." C. "Monitor for any changes in the color of your stool such as dark or black-colored stool." D. "Monitor for any changes in the color of your urine such as maroon or red-colored urine." E. Nasal cannulas can deliver oxygen concentrations up to 90%.

Correct Answer is C

Explanation

A. Ecchymosis on the abdomen or pelvic areas is not typically a sign of peptic ulcer complications, but signs of bleeding such as melena or hematemesis are.
B. Weight gain is not a common indicator of peptic ulcer issues, so it would not be a focus in this case.
C. Dark or black-colored stools are a sign of gastrointestinal bleeding, which can be a complication of a peptic ulcer and should be closely monitored.
D. Changes in urine color (maroon or red) may indicate other types of bleeding, such as from the kidneys or urinary tract, not specifically from peptic ulcers.

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A patient is experiencing anaphylaxis after receiving an antibiotic. Which interventions should the nurse prioritize to address this condition? (Select All that Apply.)

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A patient is experiencing anaphylaxis after receiving an antibiotic. Which interventions should the nurse prioritize to address this condition?
(Select All that Apply.)