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The client in the emergency department begins to experience a severe anaphylactic reaction after an initial dose of IV penicillin, an antibiotic. Which interventions should the nurse implement? Select all that apply.
- A. Prepare to administer Solu-Medrol, a glucocorticoid, IV.
- B. Request and obtain a STAT chest x-ray.
- C. Initiate the rapid response team.
- D. Administer epinephrine, an adrenergic blocker, SQ then IV continuous.
- E. Assess the client's pulse and respirations.
Correct Answer: A,C,E
Rationale: Solu-Medrol, rapid response team, and vital sign assessment address anaphylaxis. Chest x-ray is unnecessary, and epinephrine is an agonist, not a blocker.
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Which type of isolation technique is designed to decrease the risk of transmission of recognized and unrecognized sources of infections?
- A. Contact Precautions.
- B. Airborne Precautions.
- C. Droplet Precautions.
- D. Standard Precautions.
Correct Answer: D
Rationale: Standard Precautions reduce transmission of all infections by assuming all patients are infectious. Contact, airborne, and droplet precautions are for specific transmission modes.
The client on a medical floor is diagnosed with HIV encephalopathy. Which client problem is priority?
- A. Altered nutrition, less than body requirements.
- B. Anticipatory grieving.
- C. Knowledge deficit, procedures and prognosis.
- D. Risk for injury.
Correct Answer: D
Rationale: HIV encephalopathy increases confusion and motor deficits, making risk for injury the priority. Nutrition, grieving, and knowledge are secondary.
The nurse is admitting a client diagnosed with multiple sclerosis. Which clinical manifestation should the nurse assess? Select all that apply.
- A. Muscle flaccidity.
- B. Lethargy.
- C. Dysmetria.
- D. Fatigue.
- E. Dysphagia.
Correct Answer: C,D,E
Rationale: MS causes dysmetria (impaired coordination), fatigue, and dysphagia due to neurological damage. Muscle flaccidity is atypical (spasticity is common), and lethargy is non-specific.
The client diagnosed with myasthenia gravis is being discharged home. Which intervention has priority when teaching the client's significant others?
- A. Discuss ways to help prevent choking episodes.
- B. Explain how to care for a client on a ventilator.
- C. Teach how to perform passive range-of-motion exercises.
- D. Demonstrate how to care for the client's feeding tube.
Correct Answer: A
Rationale: Preventing choking is critical due to dysphagia in myasthenia gravis. Ventilator care, ROM, and feeding tubes are less common or secondary.
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.