Your patient with Iron deficiency anemia is receiving Iron Dextran when their blood pressure suddenly starts to drop, their respiratory rate increases, and their breath becomes wheezy- sounding. Your PRIORITY intervention will be:
Provide calm reassurance while reassessing blood pressure
Administer Epinephrine 1:1.000 IM
Place on Nasal Cannula 6 Lpm
Raise the HOB to high fowlers
The Correct Answer is B
A. While it’s important to provide reassurance, this option does not directly address the acute symptoms of respiratory distress and hypotension. Monitoring blood pressure is essential, but immediate action to treat the underlying issue is more critical.
B. This is the priority intervention in the case of suspected anaphylaxis. Epinephrine acts quickly to counteract severe allergic reactions, relieving bronchospasm, increasing heart rate, and raising blood pressure. Given the patient's wheezing and hypotension, administering epinephrine is crucial.
C. Administering oxygen can be beneficial, especially if the patient is experiencing respiratory distress. However, it does not address the potential anaphylactic reaction or the drop in blood pressure directly. It should be part of the management but not the priority.
D. Elevating the head of the bed can help improve breathing, especially if the patient is in respiratory distress. However, this action alone does not address the potential life-threatening aspects of anaphylaxis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. This statement is not typically related to rheumatoid arthritis. RA does not cause low blood sugar directly. While medications or other conditions might affect blood sugar levels, this is not a common symptom or concern specific to RA.
B. Morning stiffness is a hallmark symptom of rheumatoid arthritis. Patients often report increased stiffness and discomfort in their joints upon waking, which can improve with activity throughout the day.
C. While some individuals might gain weight due to reduced physical activity or medication side effects (like corticosteroids), weight loss is also common due to pain and decreased mobility. Thus, this statement is not universally applicable.
D. Abdominal pain is not a primary symptom of RA. However, certain medications used to treat RA, like nonsteroidal anti-inflammatory drugs (NSAIDs), can cause gastrointestinal discomfort, but this is not a direct result of the disease itself.
Correct Answer is B
Explanation
A. Osteoarthritis (OA) typically presents with joint pain and stiffness, but it is usually unilateral and does not cause the same types of deformities seen in RA. OA also tends to develop over time without the systemic symptoms associated with RA.
B. The combination of bilateral pain and morning stiffness in the hands, along with the presence of large nodules (likely rheumatoid nodules), swan-neck deformities, and ulnar deviation, is characteristic of rheumatoid arthritis (RA). RA is an autoimmune disorder that affects joints symmetrically and commonly leads to these specific deformities.
C. Lupus arthritis can cause joint pain and swelling, but it is often accompanied by other systemic symptoms like skin rashes (butterfly rash), fatigue, and organ involvement. The specific deformities noted (swan-neck and ulnar deviation) are more closely aligned with RA than lupus.
D. Gout is characterized by sudden, severe attacks of pain, often in the big toe or foot, and is caused by the deposition of urate crystals in the joints. It does not typically present with the deformities or patterns seen in the described patient.
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