Nokea
A client develops anaphylaxis syndrome and loses consciousness after eating fruit salad containing kiwi fruit, to which the client is severely allergic. The nurse is aware that the initial concern is which of the following?
- A. Establish a patent airway.
- B. Administer intravenous fluids.
- C. Administer oxygen at 100% high flow.
- D. Administer epinephrine.
Correct Answer: A
Rationale: In anaphylaxis with unconsciousness, the initial priority is to establish a patent airway (A) to ensure adequate oxygenation. Epinephrine (D), oxygen (C), and fluids (B) follow but are secondary to airway management.
You may also like to solve these questions
The following clients are to be assigned for daily care. The newly licensed nurse should not be assigned to provide primary care for the client with:
- A. Full-thickness burns of the abdomen and upper thighs
- B. A fractured hip scheduled for hip replacement
- C. Ileal reservoir following a cystectomy
- D. Noncardiogenic pulmonary edema (ARDS)
Correct Answer: D
Rationale: ARDS requires complex respiratory management, which is beyond the scope of a newly licensed nurse.
A preterm infant with sepsis is receiving Gentamycin (garamycin). Which physiological alteration places the preterm infant at increased risk for toxicity related to aminoglycoside therapy?
- A. Lack of subcutaneous fat deposits
- B. Immature central nervous system
- C. Presence of fetal hemoglobin
- D. Immaturity of the renal system
Correct Answer: D
Rationale: The immature renal system in preterm infants reduces the ability to excrete aminoglycosides like Gentamycin, increasing the risk of toxicity.
An RN notices an LPN in the medication room drawing up morphine. The RN asks the LPN who it is for. The LPN states that one of her clients needs pain medication. The RN offers to administer the dose, but the LPN says, 'It's ok. I can give it. I've had this client for several days and she is stable.' Which is the correct response by the nurse?
- A. Let me double-check the dose with you.
- B. OK, but let me know if you need help with anything.
- C. I am going to report this to the charge nurse immediately.
- D. You shouldn't do that. Let me chart it while you give it to save time.
Correct Answer: C
Rationale: LPNs typically cannot administer IV narcotics like morphine in most states due to scope of practice limitations. The RN should report this to the charge nurse for clarification and safety.
The registered nurse is conducting an in-service for colleagues on the subject of peptic ulcers. The nurse would be correct in identifying which of the following as a causative factor?
- A. N. gonorrhea
- B. H. influenza
- C. H. pylori
- D. E. coli
Correct Answer: C
Rationale: H. pylori is a primary causative factor in peptic ulcers, contributing to mucosal damage and ulcer formation.
A nurse is giving instructions to parents of a child who had a tonsillectomy. Which instruction is the most important?
- A. drink orange juice to relieve discomfort
- B. drink extra milk to relieve discomfort
- C. avoid drinking from a straw
- D. rinse twice a day with antiseptic mouthwash
Correct Answer: C
Rationale: Avoiding straws prevents suction that could dislodge clots and cause bleeding, a critical post-tonsillectomy precaution.