The family of a client, stung by a bee, has rushed the client to the emergency room. The client is experiencing hives and redness at the site. Upon arrival, the client states, "I feel a lump in my throat, and I am sweating. I can't breathe! I think I am going to die." The nurse anticipates which emergency treatment next?
Administer Albuterol 2 puffs stat.
Administer an injection of epinephrine stat.
Administer high-residual cannula.
Administer 5 mg prescription of the bee.
The Correct Answer is B
Choice A reason : Albuterol is a bronchodilator often used in asthma to relieve symptoms of bronchospasm. While it can help open airways, in a case of anaphylaxis, it does not address the systemic histamine release and is not the first-line treatment¹.
Choice B reason : Epinephrine is the primary treatment for anaphylaxis, which is a severe allergic reaction that can occur after a bee sting. It works rapidly to improve breathing, stimulate the heart, reverse hives, and reduce swelling of the face, lips, and throat¹³. In an emergency situation where a patient is experiencing anaphylactic symptoms such as difficulty breathing and a feeling of a lump in the throat, immediate administration of epinephrine is critical to counteract the reaction.
Choice C reason : The term "high-residual cannula" does not correspond to a recognized medical treatment or device. In the context of anaphylaxis, oxygen may be administered via a high-flow nasal cannula if the patient is experiencing respiratory distress, but this would be secondary to the administration of epinephrine.
Choice D reason : The option "Administer 5 mg prescription of the bee" is nonsensical as it does not refer to a legitimate medical treatment. In the context of bee stings, no medication is prescribed as "prescription of the bee."
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason : This statement is misleading. While heparin does need to reach a therapeutic level to be effective, it does not directly dissolve existing clots. Heparin's primary action is to prevent the formation of new clots and the extension of existing clots by inhibiting certain factors in the coagulation cascade.
Choice B reason : While a pharmacist can provide detailed information about medications, it is the nurse's responsibility to educate and inform the client about the effects of their treatment. Therefore, this response would not be appropriate.
Choice C reason : This is the most accurate response. Heparin works by inhibiting the formation of fibrin, which is essential for clot formation. It does not have the ability to dissolve existing clots but can prevent new ones from forming and existing ones from getting larger.
Choice D reason : Oral medications such as warfarin or direct oral anticoagulants (DOACs) may be used after heparin to maintain anticoagulation; however, they also do not dissolve clots. The body's natural fibrinolytic system is responsible for breaking down clots over time.
Correct Answer is D
Explanation
Choice A reason : Delegating the NG tube placement to a more experienced nurse does not address the client's refusal of the procedure. The nurse must respect the client's autonomy and decision-making rights.
Choice B reason : While a referral to Social Services may be appropriate in some cases, it does not directly address the immediate concern of the client's refusal of the NG tube placement.
Choice C reason : Seeking consent from the client's spouse is not appropriate as the client is competent and has the right to refuse treatment. The client's autonomy must be respected.
Choice D reason : Documenting the client's wishes and notifying the physician is the correct action. The nurse must respect the client's right to refuse treatment and communicate this decision to the physician so that alternative management can be considered.
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