Ten minutes following administration of an antibiotic, the nurse assesses a patient to have edematous lips, hoarseness, and expiratory stridor. Vital signs assessed by the nurse include blood pressure 70/40 mm Hg, heart rate 130 beats/min, and respirations 36/min. What is the priority intervention?

Diphenhydramine (Benadryl)

Epinephrine

Methylprednisone (Solu-Medrol)

Ranitidine (Zantac)

Answer and Explanation

The Correct Answer is B

Rationale:
A. Diphenhydramine (Benadryl) is incorrect as the first-line intervention because, although it blocks H1 histamine receptors and can reduce urticaria and itching, it does not act quickly enough to reverse airway obstruction, bronchospasm, or hypotension caused by anaphylaxis. Relying solely on diphenhydramine could result in progressive airway compromise or cardiovascular collapse.

B. Epinephrine is correct because the patient is experiencing anaphylactic shock, evidenced by rapid-onset airway compromise (stridor, hoarseness, lip edema) and circulatory collapse (hypotension, tachycardia, tachypnea). Epinephrine works immediately to vasoconstrict, increase blood pressure, reduce mucosal edema, and bronchodilate, making it the life-saving priority intervention.

C. Methylprednisolone (Solu-Medrol) is incorrect as the initial intervention because corticosteroids act slowly (hours) to reduce inflammation and cannot prevent imminent airway obstruction or restore blood pressure during acute anaphylaxis. They are considered adjunct therapy after epinephrine administration.

D. Ranitidine (Zantac) is incorrect because H2 blockers block histamine at H2 receptors, which may help reduce cutaneous symptoms or gastric acid effects but do not relieve airway edema, bronchospasm, or hypotension. They are used as secondary, supportive treatment after epinephrine, not as primary therapy.

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Correct Answer is C

Explanation

Rationale:

A. 53 mm Hg would indicate severe hypotension and does not match the calculation.
B. 86 mm Hg is higher than the calculated value and would suggest better perfusion than reflected by the BP provided.
C. A MAP of 73 mm Hg is the accurate calculation and is just above the minimum MAP of 65 mm Hg needed to maintain adequate organ perfusion.

To calculate mean arterial pressure (MAP), use the formula:

MAP = (Systolic BP + 2 × Diastolic BP) ÷ 3

Substitute the given values:
MAP = (100 + 2 × 60) ÷ 3
MAP = (100 + 120) ÷ 3
MAP = 220 ÷ 3
MAP ≈ 73 mm Hg
D. 110 mm Hg reflects systolic pressure, not MAP.

A. WBC 13.8 B. Hgb 14.4 C. Platelets 98 D. Glucose 140 E. Lactate 3.2

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

Explanation

Rationale:
A. WBC 13.8 is correct because leukocytosis indicates infection or systemic inflammatory response, consistent with her urinary symptoms and altered mental status. This lab result supports the need for immediate evaluation and treatment of a suspected urinary tract infection or sepsis.

B. Hgb 14.4 is incorrect because this value is within normal limits for an adult female and does not indicate acute pathology requiring intervention.

C. Platelets 98 is correct because thrombocytopenia (<150,000) may indicate consumption from sepsis or early disseminated intravascular coagulation (DIC). Low platelets increase the risk for bleeding and are clinically significant in a patient with suspected infection.

D. Glucose 140 is incorrect because this value is mildly elevated and may be stress-induced hyperglycemia, which is common in acute illness. While it should be monitored, it does not require immediate intervention.

E. Lactate 3.2 is correct because elevated serum lactate (>2 mmol/L) indicates tissue hypoperfusion and risk of severe sepsis or septic shock. This is a critical finding requiring urgent recognition and intervention, such as fluid resuscitation, antibiotics, and close hemodynamic monitoring.

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Ten minutes following administration of an antibiotic, the nurse assesses a patient to have edematous lips, hoarseness, and expiratory stridor. Vital signs assessed by the nurse include blood pressure 70/40 mm Hg, heart rate 130 beats/min, and respirations 36/min. What is the priority intervention?

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Correct Answer is C

Explanation

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

Explanation

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