What action priority in preventing anaphylactic shock?
Removal of the educating patient to carry an Epipen
Assess and document for previous allergies and drug reactions prior to medication administration
Administer diphenhydramine and solumedrol IV and solumedrol IV at the first sign of allergic symptoms
Application of red allergy bracelet patient's upper extremity
The Correct Answer is B
A. Removal of the educating patient to carry an Epipen
While educating the patient about carrying an Epipen is essential in managing anaphylaxis, it is not the primary action in preventing anaphylactic shock before exposure to an allergen.
B. Assess and document for previous allergies and drug reactions prior to medication administration
Identifying and documenting allergies before administering medications or treatments helps prevent exposure to known allergens, reducing the risk of anaphylaxis.
C. Administer diphenhydramine and solumedrol IV at the first sign of allergic symptoms
These medications help in managing allergic reactions but do not prevent anaphylactic shock. Preventive measures focus on avoiding allergen exposure rather than treating symptoms after they occur.
D. Application of a red allergy bracelet on the patient’s upper extremity
This helps alert healthcare providers about allergies, but it does not prevent anaphylactic shock. It is a precautionary step rather than a primary prevention strategy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
A. Reassure the client that information they share with the nurse is confidential
Establishing trust and confidentiality is essential in a health interview, especially for clients with neurological deficits who may feel vulnerable.
B. Instruct that complementary therapies are rarely helpful
This statement is not evidence-based and may dismiss patient preferences. Some complementary therapies, such as physical therapy or mindfulness, can be helpful in neurological conditions.
C. Assess physical appearance and gait
Observing physical appearance and gait provides important clues about neurological deficits, such as weakness, ataxia, or tremors.
D. Review current medication list including dosage & frequency
Medication history is critical in neurological assessments, as certain medications (e.g., anticoagulants, anticonvulsants) can impact the client’s condition.
E. Ask about current alcohol or drug use
Alcohol and drug use can contribute to neurological impairment and should be assessed during the history-taking process.
Correct Answer is C
Explanation
A. Massive blood loss leading to decreased oxygen delivery to tissues
This describes hypovolemic shock, which occurs due to significant blood or fluid loss (e.g., hemorrhage, severe dehydration). In this scenario, there is no evidence of massive blood loss, making hypovolemic shock unlikely.
B. Severe allergic reaction causing systemic vasodilation and increased capillary permeability
This describes anaphylactic shock, which results from an acute allergic reaction (e.g., to food, medication, insect stings). There is no mention of an allergen exposure or symptoms like wheezing, stridor, or urticaria, making anaphylactic shock unlikely.
C. Infection causing a systemic inflammatory response leading to vasodilation and decreased tissue perfusion
This patient is exhibiting signs of septic shock, which occurs as a result of a severe infection leading to systemic inflammatory response syndrome (SIRS). The presence of fever, tachycardia, tachypnea, hypotension, and altered mental status strongly suggests sepsis progressing to septic shock.
D. Cardiac failure resulting in inadequate tissue perfusion and oxygenation
This describes cardiogenic shock, which occurs due to heart failure (e.g., from myocardial infarction, cardiomyopathy). It leads to low cardiac output, pulmonary congestion, and organ hypoperfusion. This patient’s infection and systemic inflammation suggest septic shock, not a primary cardiac event.
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