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 C
Explanation
A. "Use the peak expiratory flow meter once per week." The peak expiratory flow meter is usually recommended for daily use in asthma management to monitor lung function and detect any changes early.
B. "Take cromolyn sodium at the first sign of breathing difficulty." Cromolyn sodium is a mast cell stabilizer and is used as a preventative medication rather than for quick relief of symptoms, so it should be taken regularly as prescribed, not only when symptoms arise.
C. "Avoid triggers that cause an attack." Avoiding known asthma triggers is an important part of asthma management to prevent attacks and exacerbations.
D. "You should stop playing basketball, but you can swim instead." Exercise should not necessarily be avoided; instead, it should be managed appropriately with pre-treatment if needed. Avoiding all sports activities is not generally recommended.