Nokea
A client is in the hospital and has received two doses of an angiotensin-converting enzyme for hypertension. When the nurse answers the client's call light, the client presents an appearance as shown below: What action by the nurse takes is most appropriate?
Correct Answer: C
Rationale: The correct action by the nurse is to ensure a patent airway while calling the Rapid Response Team (Choice C). This is because the client is showing signs of angioedema, a potential adverse reaction to angiotensin-converting enzyme (ACE) inhibitors. Angioedema can lead to airway compromise and respiratory distress, hence ensuring a patent airway is crucial. Additionally, calling the Rapid Response Team will allow for immediate medical intervention and monitoring of the client's condition.
Choice A (Administer epinephrine) is incorrect as epinephrine is not the first-line treatment for angioedema associated with ACE inhibitors. Choice B (Apply oxygen) is not sufficient to address the potential airway compromise. Choice D (Reassure the client) is inappropriate as the client's condition requires immediate action to address the potential airway obstruction.