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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. This is not typical for Raynaud's phenomenon. Instead, Raynaud's is characterized by episodes of reduced blood flow to the extremities, often triggered by cold or stress, leading to sensations of coldness or numbness rather than warmth.
B. This finding aligns with Raynaud's phenomenon. During an episode, the blood vessels constrict in response to cold or stress, leading to pallor (whiteness) in the affected areas, such as the toes and fingers. This is a classic symptom of the condition.
C. While feet can become reddened due to increased blood flow after rewarming or after exposure to warmth, this is not a characteristic feature of Raynaud's phenomenon. In Raynaud's, the affected areas typically exhibit color changes from white (pallor) to blue (cyanosis) and then red (hyperemia) as blood flow returns, but redness upon ambulation is not specifically indicative of the phenomenon.
D. Swelling of the joints can occur in SLE due to arthritis or inflammation but is not a direct symptom of Raynaud's phenomenon. Raynaud's primarily affects blood flow and does not inherently cause joint swelling; however, a client with SLE may experience joint symptoms due to other underlying inflammatory processes.

A. TPN should flow through a filtered IV line B. No other drugs should be infused through the TPN line C. If TPN gets stopped or runs out, hang a bag of D10% W D. TPN IV tubing and bag should be changed every 24 hrs E. TPN should be administered through a central line

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

Explanation

A. Using a filtered IV line helps remove any particulate matter that could be present in the TPN solution, reducing the risk of complications such as phlebitis or embolism.
B. TPN should have its own dedicated line to prevent incompatibilities and ensure the TPN solution is delivered without interference. Infusing other medications through the same line can lead to complications and reduce the effectiveness of TPN.
C. If TPN gets stopped or runs out, a bag of 5% dextrose in water (D5W) should be hung to prevent hypoglycemia. D10% is too concentrated and can cause hyperglycemia.
D. To minimize the risk of infection and maintain sterility, TPN bags and tubing should be replaced every 24 hours. This helps prevent bacterial growth in the TPN solution.
E. TPN is typically administered through a central line because it allows for the infusion of hypertonic solutions that can irritate peripheral veins. Central lines provide better access to larger blood vessels, reducing the risk of complications.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has SLE and is experiencing an episode of Raynaud's phenomenon. Which of the following findings should the nurse anticipate?

Correct Answer is B

Explanation

Which of the following is are appropriate nursing interventions to ensure the safety of a patient who is receiving Total Parenteral Nutrition (TPN)? (Select all that apply)

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

Explanation

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