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 B
Explanation
A. Respiratory distress syndrome occurs in babies with frequent colds. This statement is inaccurate; respiratory distress syndrome (RDS) is not associated with frequent colds.
B. Respiratory distress syndrome occurs in premature and low-birth-weight babies. This statement accurately describes RDS, as it is primarily seen in premature infants due to insufficient surfactant production.
C. Respiratory distress syndrome occurs in babies with genetic allergies. RDS is not directly related to genetic allergies; it is a condition primarily linked to prematurity and lung maturity.
D. Respiratory distress syndrome occurs in babies stressed during the pregnancy. While stress during pregnancy can affect outcomes, RDS is specifically associated with lung development in premature infants rather than stress alone.
Correct Answer is C
Explanation
A. Hypertension: While systemic corticosteroids can lead to hypertension, fluticasone, when inhaled, typically has minimal systemic effects.
B. Polyuria: Polyuria is more associated with systemic corticosteroids or diabetes management, not with inhaled fluticasone.
C. Oral candidiasis: Inhaled corticosteroids like fluticasone can lead to oral thrush, so rinsing the mouth after use is advised to prevent this.
D. Hypoglycemia: Corticosteroids typically cause hyperglycemia rather than hypoglycemia.