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. "Gradually decrease the dose once tolerance to the effect is reached." Tolerance can develop over time, but this approach is not the most effective or safest way to manage sedation.
B. "Take the medication with meals." Taking diphenhydramine with food may help with gastrointestinal side effects but does not reduce sedation.
C. "Distribute the doses evenly throughout the day." Distributing doses evenly may not effectively reduce sedation, as diphenhydramine has sedative effects regardless of timing.
D. "Take the daily dose at bedtime.” Taking diphenhydramine at bedtime can minimize daytime sedation, as the sedative effects will occur during sleep.
Correct Answer is A
Explanation
A. "This is a common side effect with albuterol and will stop soon." Nervousness and shakiness are common side effects of albuterol due to its action as a bronchodilator and stimulant.
B. "You are having an allergic reaction, and I should notify the provider." The symptoms described are not indicative of an allergic reaction but rather a common side effect of the medication.
C. "The albuterol is probably interacting with another medication." While drug interactions can occur, the reported symptoms are typical side effects of albuterol.
D. "The albuterol is not working, and you will need another medication." The symptoms do not indicate that the medication is ineffective; they are more indicative of its stimulant effects.