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","C","D"]
Explanation
A. Perform passive range of motion exercises. Passive range of motion exercises help maintain circulation and reduce venous stasis, which is crucial for preventing pulmonary embolism in clients who are immobile.
B. Place pillows under the client's knees when in bed. Placing pillows under the knees can actually promote venous stasis and increase the risk of a pulmonary embolism. It is better to keep the legs flat to encourage circulation.
C. Assess legs for redness. Regular assessment of the legs for redness, swelling, or warmth helps in the early detection of deep vein thrombosis (DVT), which can lead to pulmonary embolism if not addressed.
D. Apply elastic compression stockings. Elastic compression stockings promote venous return from the legs to the heart and help prevent DVT, thereby reducing the risk of pulmonary embolism.
E. Massage the calves every shift. Massaging the calves can dislodge a thrombus and potentially lead to a pulmonary embolism. Instead, interventions should focus on preventing thrombus formation.
Correct Answer is ["C","D","E"]
Explanation
A. Stimulate production of androgens: The kidneys do not stimulate androgen production. Androgens are produced primarily by the adrenal glands and gonads.
B. Stimulate production of white blood cells: The kidneys do not stimulate white blood cell production. This is mainly a function of the bone marrow.
C. Excrete various drugs and drug metabolites: The kidneys play a key role in filtering and excreting drugs and drug metabolites, helping to remove them from the body.
D. Produce urine: The primary function of the kidneys is to filter blood and produce urine, which is then excreted to remove waste products and maintain fluid balance.
E. Regulate acid/base balance: The kidneys are essential in maintaining acid-base balance by excreting hydrogen ions and reabsorbing bicarbonate, which helps regulate the pH level in the body.