A patient stung by a bee presents to the emergency department. The patient is experiencing hives and redness at the site. Upon arrival, the patient states, "I feel a lump in my throat and I am sweating. I can't breathe!! think I am going to die!" The nurse anticipates which emergency treatment next?

Administer an injection of epinephrine stat.

Administer oxygen 4 liters via nasal cannula.

Administer albuterol 2 puffs stat.

Have the patient in high Fowler's position in the bed.

Answer and Explanation

The Correct Answer is A

A. Administer an injection of epinephrine stat: The patient’s symptoms are classic signs of anaphylaxis, a severe IgE-mediated hypersensitivity reaction. Epinephrine is the first-line treatment because it stimulates alpha-1 receptors (causing vasoconstriction to reduce edema and hypotension) and beta-2 receptors (producing bronchodilation). Immediate intramuscular administration prevents airway obstruction and cardiovascular collapse.

B. Administer oxygen 4 liters via nasal cannula: Supplemental oxygen supports oxygenation during respiratory distress but does not reverse the underlying pathophysiology of anaphylaxis. It does not address airway edema, bronchospasm, or vasodilation. Oxygen is an important adjunct after epinephrine, but it is not the priority intervention in a rapidly progressing allergic reaction.

C. Administer albuterol 2 puffs stat: Albuterol is a beta-2 agonist that provides bronchodilation and may help relieve bronchospasm. However, it does not reduce laryngeal edema or counteract systemic vasodilation and hypotension. In anaphylaxis, albuterol is considered secondary therapy and should not delay epinephrine administration.

D. Have the patient in high Fowler's position in the bed: Positioning may help ease breathing effort by optimizing lung expansion. However, it does not treat airway edema, bronchoconstriction, or the systemic vasodilatory effects of anaphylaxis. Supportive measures such as positioning are important but must follow immediate administration of epinephrine.

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Correct Answer is A

Explanation

A. Keep the head of the bed elevated to 30 degrees: Elevating the head of the bed promotes venous drainage from the brain, reducing intracranial pressure (ICP) caused by cerebral edema. Proper head positioning is a noninvasive, evidence-based intervention to prevent further neurologic compromise while maintaining cerebral perfusion.

B. Position the patient with knees and hips flexed: Flexing the hips and knees can increase intra-abdominal and intrathoracic pressure, which may impair venous return from the brain and exacerbate elevated ICP. For patients with cerebral edema, supine or semi-Fowler positions with slight head elevation are preferred.

C. Administer pain medications at frequent intervals: Pain control is important in head injury management, but excessive sedation or overuse of opioids can mask neurologic changes and alter the assessment of ICP. Analgesics should be administered judiciously and as indicated, not at fixed frequent intervals.

D. Encourage coughing and deep breathing: While deep breathing prevents atelectasis, coughing increases intrathoracic and intracranial pressure, which can worsen cerebral edema. Pulmonary hygiene must be balanced with interventions to minimize ICP, such as gentle suctioning and controlled ventilatory support if needed.

A. Avoid IM injections B. Avoid rectal thermometers C. Use a soft toothbrush D. Administer aspirin for headache E. Monitor stools for occult blood

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

Explanation

A. Avoid IM injections: In immune thrombocytopenic purpura (ITP), platelet counts are low, increasing the risk of bleeding and hematoma formation with intramuscular injections. Using alternative routes such as oral or subcutaneous administration when possible reduces trauma to the tissues and prevents uncontrolled bleeding.

B. Avoid rectal thermometers: Rectal instrumentation can cause mucosal trauma and bleeding in patients with thrombocytopenia. Avoiding rectal thermometers helps prevent localized hemorrhage, which can be difficult to control in patients with ITP.

C. Use a soft toothbrush: Patients with ITP are at increased risk of oral mucosal bleeding due to low platelet counts. Using a soft-bristled toothbrush minimizes trauma to the gums during oral hygiene and reduces the risk of gingival bleeding.

D. Administer aspirin for headache: Aspirin has antiplatelet effects and can exacerbate bleeding tendencies in ITP. It should be avoided; alternative analgesics like acetaminophen are preferred. Administering aspirin could precipitate serious hemorrhagic complications.

E. Monitor stools for occult blood: Gastrointestinal bleeding is a potential complication of ITP. Monitoring stools for occult blood allows early detection of internal bleeding, even in the absence of overt symptoms, enabling timely intervention and management of hemorrhagic events.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient who is unconscious after a head injury has cerebral edema. Which nursing intervention will be included in the plan of care?

Correct Answer is A

Explanation

Which nursing interventions are appropriate for managing ITP? Select all that apply.

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

Explanation

Prescribed: Begin propofol IV infusion at 9 mL/hr Available: propofol 1000 mg/100 mL Patient's weight: 75 kg Calculate how many mcg/kg/min the patient is receiving? Record your answer to whole number.

A nurse is assessing a patient admitted with fever, severe headache, and photophobia. Which assessment finding would most strongly support a diagnosis of bacterial meningitis?

A patient enters the Emergency Department complaining of nausea and vomiting. The nurse notes a sweet, fruity breath odor, Blood glucose reveals 540 mg/dl. What does the nurse recognize as the priority intervention?

A patient with an oral endotracheal (ET) tube has tube feeding in progress. To address the risk for aspiration, the nurse will perform which intervention for this patient?

A patient who has been involved in a motor-vehicle crash is admitted to the emergency department in shock, Of the prescribed orders, below, which order will the nurse implement first?

The nurse anticipates that positive-end-expiratory-pressure (PEEP) will be utilized when a patient with acute respiratory distress syndrome (ARDS) is placed on mechanical ventilation for which purpose?