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 A

Explanation

A. This statement indicates some understanding of self-care, as using gentle hair products can help minimize irritation. However, it's not specifically focused on the most critical aspects of SLE management related to skin care.
B. Clients with SLE should inspect their skin regularly, not just once a month, as they are at a higher risk for rashes and skin lesions. More frequent self-assessment can help catch any changes early.
C. Clients with SLE are generally advised to avoid tanning beds altogether, as ultraviolet (UV) exposure can exacerbate skin rashes and trigger flares of the disease. Limiting exposure to UV light is essential for managing lupus.
D. Applying powder to a rash may not be advisable, as it could irritate the skin further. Clients should be taught to keep the affected areas clean and follow their healthcare provider's recommendations for treating rashes.

A. Use paper tape on fragile skin B. Provide mouthwash with alcohol for oral care C. Avoid aspirin D. Provide a soft bristle toothbrush or oral sponge E. Teach to use an electric shaver instead of a razor

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

Explanation

A. Paper tape is gentler on fragile skin compared to standard adhesive tape. It reduces the risk of skin tears and bleeding, making it a safer option for patients with thrombocytopenia.
B. This option is not advisable. Mouthwash containing alcohol can irritate and dry out the mucous membranes in the mouth, potentially leading to ulcers or bleeding. Instead, an alcohol-free mouthwash should be used for oral care.
C. Aspirin is an antiplatelet agent that can increase the risk of bleeding. Patients on bleeding precautions should avoid aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) to minimize the risk of excessive bleeding.
D. A soft-bristle toothbrush or oral sponge is recommended for oral care to minimize trauma to the gums and mucous membranes. This helps reduce the risk of bleeding in patients with low platelet counts.
E. Using an electric shaver is safer than a traditional razor, as it reduces the risk of cuts and nicks that can lead to bleeding. This precaution is particularly important for patients with thrombocytopenia.

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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 teaching a client who has SLE (Lupus) about self-care. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

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

Explanation

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