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. Tachycardia: Theophylline can cause tachycardia as a side effect due to its stimulant properties.
B. Constipation: While gastrointestinal effects can occur, constipation is not a common or significant adverse effect of theophylline.
C. Oliguria: Theophylline is more likely to cause diuresis rather than oliguria.
D. Drowsiness: Theophylline typically causes stimulation rather than sedation, leading to increased alertness rather than drowsiness.
Correct Answer is C
Explanation
A. Urine-specific gravity: While urine-specific gravity can provide information on kidney function, it does not specifically measure renal impairment or disease progression, especially in SLE.
B. Serum potassium: Serum potassium levels can be affected by renal function but are not a direct indicator of renal health and can be influenced by many other factors.
C. Serum creatinine: Serum creatinine is a more reliable indicator of renal function, as it reflects how well the kidneys are filtering waste. In clients with SLE, kidney involvement is a common complication.
D. Serum sodium: Serum sodium levels do not directly indicate renal function, though kidney impairment can impact electrolyte levels.