Which assessment information is most important for the nurse to obtain when evaluating whether treatment of a patient with anaphylactic reaction has been effective?
Blood Pressure
Oxygen Saturation.
Heart Rate.
Orientation.
The Correct Answer is A
Anaphylaxis is a severe and potentially life-threatening allergic reaction that can lead to a rapid drop in blood pressure, known as hypotension. This drop in blood pressure is a critical indicator of the severity of the reaction and the effectiveness of the treatment provided. The nurse needs to monitor the patient's blood pressure closely to ensure it stabilizes and returns to a safe range.
While oxygen saturation, heart rate, and orientation are also important parameters to assess, they are secondary to blood pressure in evaluating the effectiveness of treatment for anaphylaxis. Oxygen saturation can help determine the adequacy of oxygenation, heart rate can indicate the presence of tachycardia (which may be a sign of an ongoing reaction or hypoperfusion), and orientation can provide information about the patient's mental status and potential complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
In a child with acute appendicitis, it is common to observe an elevated white blood cell count (WBC) as a response to the infection or inflammation associated with the condition. The neutrophil count may be within the lower end of the normal range or slightly decreased, as it can be affected by the severity and duration of the appendicitis. The red blood cell count (RBC) appears to be within the normal range. The lactic acid level is normal, indicating no significant metabolic acidosis.
Correct Answer is D
Explanation
The nurse should inform the client that a common side effect of Lisinopril, an ACE inhibitor, is a chronic dry cough. ACE inhibitors can cause irritation in the respiratory tract, leading to a persistent cough. It is important for the client to be aware of this side effect and report it to their healthcare provider if it becomes bothersome.
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