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 B
Explanation
A. Encouraging the patient to take deep breaths and cough would not address the underlying cause of the symptoms, which may indicate a more serious condition.
B. Administering oxygen to maintain adequate oxygenation is the most appropriate initial action, as the patient’s symptoms suggest a potentially life-threatening condition like a cardiac tamponade or pulmonary embolism.
C. Positioning the patient flat in bed is not recommended, as it may exacerbate breathing difficulties and
the patient’s distress.
D. A warm compress is unlikely to be beneficial in this acute situation and could delay appropriate intervention.
Correct Answer is C
Explanation
A. Airway obstruction in asthma is not caused by thinning mucus. It is primarily due to bronchospasm, inflammation, and thickening of the mucus.
B. Decreased mucus production does not contribute to airway constriction in asthma. In fact, excessive mucus production is a key feature of asthma, leading to obstruction of the airways.
C. Bronchospasm in asthma involves inflammation, edema, and excess mucus production. These factors cause narrowing of the airways, leading to difficulty breathing.
D. Inflammation leads to airway narrowing, but it does not reduce the airway diameter in the sense of preventing bronchospasm. Bronchospasm occurs as a result of inflammation and muscle contraction.
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