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

Answer and Explanation

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.

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

Explanation

A. Distributive shock

Severe burns lead to systemic inflammatory response syndrome (SIRS), causing massive vasodilation, similar to septic shock (a type of distributive shock).

D. Hypovolemic shock

Fluid loss from burns leads to hypovolemic shock, which is the most common type of shock seen in burn patients.

B. Cardiogenic shock

Cardiogenic shock is caused by heart failure and is not a primary concern in burn injuries.

C. Obstructive shock

Obstructive shock (e.g., tension pneumothorax, cardiac tamponade) does not occur in burn patients unless another condition is present.

E. Neurogenic shock

Neurogenic shock occurs from spinal cord injuries, not burns.

A. Auscultate bowel sounds, record the findings and obtain a 12-lead ECG B. Initiate the standing prescription for v Dopamine at 16 mcg/kg/minute C. Place soft restraints on the upper extremities and sedate as necessary D. Lower the head the bed obtain a pulse ox and increase the rate of iv fluids

Correct Answer is D

Explanation

A. Auscultate bowel sounds, record the findings, and obtain a 12-lead ECG
While auscultating bowel sounds can help assess for bowel injury and an ECG is useful for monitoring cardiac function, these interventions are not the priority. The client is in shock and requires immediate intervention to restore perfusion.

B. Initiate the standing prescription for Dopamine at 16 mcg/kg/minute
Dopamine can be used to support blood pressure in shock, but fluid resuscitation is the first-line intervention in hypovolemic shock. Vasopressors like dopamine are typically added after fluid resuscitation if hypotension persists.

C. Place soft restraints on the upper extremities and sedate as necessary
The client's restlessness is likely due to hypoxia and inadequate perfusion, not agitation. Restraints and sedation would delay critical interventions and could worsen hemodynamic instability.

D. Lower the head of the bed, obtain a pulse ox, and increase the rate of IV fluids
The client is in hypovolemic shock due to suspected internal bleeding. Lowering the head of the bed improves cerebral perfusion, increasing IV fluids restores intravascular volume, and checking pulse oximetry ensures adequate oxygenation. This is the priority action to stabilize the client.

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What action priority in preventing anaphylactic shock?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with major bums Total Body Surface Area (TBSA) of 63%. The nurse understands that this patient is at the highest risk for the combination of which types of shock? (Select All that Apply.)

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

Explanation

Correct Answer is D

Explanation

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