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. 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.
Correct Answer is C
Explanation
A. Friction rub: A friction rub is usually associated with pleuritis, not atelectasis. Atelectasis involves the collapse of alveoli and does not produce this sound.
B. Decreasing respiratory rate: Atelectasis generally leads to an increased respiratory rate as the body compensates for decreased oxygenation.
C. Increasing dyspnea: Increasing dyspnea is common in atelectasis as collapsed alveoli reduce oxygen exchange, leading to shortness of breath and increased respiratory effort.
D. Facial flushing: Facial flushing is not typically associated with atelectasis; instead, atelectasis leads to signs of respiratory distress, such as dyspnea and possibly cyanosis.