A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first?
Vomiting
Stridor
Hypertension
Urticaria
The Correct Answer is B
A. Vomiting: While vomiting can occur during anaphylaxis, it is not the most immediately life-threatening symptom.
B. Stridor: Stridor indicates upper airway obstruction, which is a critical and life-threatening sign of anaphylaxis. This finding requires immediate intervention, such as administering epinephrine and ensuring airway patency.
C. Hypertension: Hypertension is not typically associated with anaphylaxis; instead, hypotension is more common due to vascular collapse.
D. Urticaria: Urticaria (hives) can occur in anaphylaxis, but it is not as urgent as stridor, which indicates a compromised airway.
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Correct Answer is D
Explanation
A. Narrowed pulse pressure: A narrowed pulse pressure can indicate various cardiovascular issues but is not a specific sign of pneumonia.
B. Bradycardia: Bradycardia may occur due to various reasons, including medications or underlying health conditions, but it is not a common sign of pneumonia.
C. Night sweats: While night sweats can occur with pneumonia, they are more associated with infections such as tuberculosis or certain malignancies. It's not a classic presentation.
D. Confusion: Confusion is a common manifestation of pneumonia in older adults due to hypoxia, dehydration, or fever. Older adults often present atypically with changes in mental status during infections.
Correct Answer is B
Explanation
A. “If my breathing begins to feel tight, I will use the fluticasone immediately." Fluticasone is a corticosteroid, and it is not a rescue medication. It is used for long-term control and does not provide immediate relief for acute symptoms.
B. "I will be sure to use the albuterol nebulizer before the fluticasone." Albuterol is a bronchodilator and should be used first to open the airways, allowing better absorption of fluticasone when used afterward.
C. "I do not need to rinse my mouth after completing the albuterol and fluticasone." Rinsing the mouth after using fluticasone (a corticosteroid) is important to prevent oral thrush. Albuterol alone does not require rinsing, but fluticasone does.
D. "I will use both medications immediately after exercising." Albuterol is often used as a pre-exercise medication for asthma, but fluticasone should be used as directed for maintenance, not as an immediate post-exercise medication.