Nokea
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.
You may also like to solve these questions
The nurse is preparing to administer morning medications. Which medication should the nurse administer first?
- A. The pain medication to a client diagnosed with RA.
- B. The diuretic medication to a client diagnosed with SLE.
- C. The steroid to a client diagnosed with polymyositis.
- D. The appetite stimulant to a client diagnosed with OA.
Correct Answer: C
Rationale: Steroids for polymyositis address inflammation and muscle weakness, a priority in autoimmune disease. Pain, diuresis, and appetite are less urgent.
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 discussing autoimmune diseases with a class of nursing students. Which signs and symptoms are shared by rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE)?
- A. Nodules in the subcutaneous layer and bone deformity.
- B. Renal involvement and pleural effusions.
- C. Joint stiffness and pain.
- D. Raynaud's phenomenon and skin rash.
Correct Answer: C
Rationale: Joint stiffness and pain are common to both RA and SLE. Nodules and deformities are RA-specific, renal/pleural issues are more SLE-specific, and Raynaud’s/rash are not universal in RA.
The nurse is explaining Systemic Inflammatory Response Syndrome (SIRS) to the client's significant other. Which statement best describes SIRS?
- A. SIRS is a response of the body when it has sustained a major burn or crushing injury in a motor-vehicle accident.
- B. SIRS is a response by the body to some type of injury or insult; the insult can be infectious or noninfectious in nature.
- C. SIRS only occurs when the body is overwhelmed with an infectious organism such as streptococcus bacteria.
- D. SIRS occurs when the body is allergic to the prescribed antibiotic and the body tries to recover from the allergic response.
Correct Answer: B
Rationale: SIRS is a systemic response to various insults (e.g., infection, trauma, surgery), not limited to specific causes. Burns, infections, and allergies are subsets.
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.