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 A
Explanation
A. Daily or weekly weight: Daily or weekly weight measurements are a reliable way to assess fluid retention. A sudden increase in weight can indicate fluid overload.
B. Sodium level: While sodium levels can provide some information about fluid balance, they are not as direct or reliable as weight measurements for assessing fluid retention.
C. Tissue turgor: Tissue turgor can give some insight into hydration status but is subjective and less reliable compared to weight measurements, especially in clients with chronic conditions.
D. Intake and output: While monitoring intake and output is important for assessing fluid balance, it may not accurately reflect fluid retention, as it doesn't account for fluid shifts or loss through other routes.
Correct Answer is B
Explanation
A. Distribution of protein: While protein distribution may be affected in kidney disease, it is not a primary function of the kidneys.
B. Filtration of the blood: The kidneys are responsible for filtering waste products and excess substances from the blood. In kidney failure, this filtration process is impaired, leading to the accumulation of toxins in the body.
C. Metabolism of medications: Although the kidneys do play a role in drug excretion, drug metabolism primarily occurs in the liver. Kidney failure may affect the excretion phase.
D. Ability to hold urine: While kidney failure can affect urinary function, the ability to hold urine is primarily a bladder function, not directly a function of the kidneys.