Nokea
The client comes to the emergency department complaining of dyspnea and wheezing after eating at a seafood restaurant. The client cannot speak and has a bluish color around the mouth. Which intervention should the nurse implement first?
- A. Initiate an IV with normal saline.
- B. Prepare to intubate the client.
- C. Administer oxygen at 100%.
- D. Ask the client about an iodine allergy.
Correct Answer: C
Rationale: Administering 100% oxygen addresses immediate hypoxia in anaphylaxis, per ABCs. IV fluids, intubation, and allergy history follow.
You may also like to solve these questions
The client in the HCP's office has a red, raised rash covering the forearms, neck, and face and is experiencing extreme itching which is diagnosed as an allergic reaction to poison ivy. Which discharge instructions should the nurse teach?
- A. Tell the client never to scratch the rash.
- B. Instruct the client in administering IM Benadryl.
- C. Explain how to take a steroid dose pack.
- D. Have the client wear shirts with long sleeves and high necks.
Correct Answer: C
Rationale: A steroid dose pack reduces inflammation and itching in poison ivy reactions. Never scratching is unrealistic, IM Benadryl is HCP-administered, and clothing is preventive.
The client with acquired immunodeficiency syndrome (AIDS) dementia is referred to hospice. Which intervention has highest priority when caring for the client in the home?
- A. Assess the client's social support network.
- B. Identify the client's usual coping methods.
- C. Have consistent uninterrupted time with the client.
- D. Discuss and complete an advance directive.
Correct Answer: D
Rationale: Completing an advance directive ensures end-of-life wishes are honored, a priority in hospice. Support, coping, and time are secondary.
The client diagnosed with multiple sclerosis is having trouble maintaining balance. Which intervention should the nurse discuss with the client?
- A. Discuss obtaining a motorized wheelchair for the client.
- B. Teach the client to stand with the feet slightly apart.
- C. Encourage the client to narrow his or her base of support.
- D. Explain the need to balance activity with rest.
Correct Answer: B
Rationale: Standing with feet apart widens the base of support, improving balance in MS. Wheelchairs are premature, narrowing support worsens balance, and rest is secondary.
The client diagnosed with RA who has been prescribed etanercept, a tumor necrosis factor alpha inhibitor, shows marked improvement. Which instruction regarding the use of this medication should the nurse teach?
- A. Explain the medication loses its efficacy after a few months.
- B. Continue to have checkups and laboratory work while taking the medication.
- C. Have yearly magnetic resonance imaging to follow the progress.
- D. Discuss the drug is taken for three (3) weeks and then stopped for a week.
Correct Answer: B
Rationale: Regular checkups and lab work monitor for etanercept side effects (e.g., infection). Efficacy persists, MRI is not routine, and cycling is incorrect.
Which is the highest priority nursing intervention for the client who is having an anaphylactic reaction?
- A. Administer parenteral epinephrine, an adrenergic agonist.
- B. Prepare for immediate endotracheal intubation.
- C. Provide a calm assurance when caring for the client.
- D. Establish and maintain a patent airway.
Correct Answer: D
Rationale: Establishing a patent airway is the highest priority in anaphylaxis, per ABCs. Epinephrine, intubation, and reassurance follow.