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 D
Explanation
A. "I will rinse my mouth after each dose to prevent thrush." Ipratropium bromide is an anticholinergic bronchodilator, and it does not typically increase the risk of oral thrush. Rinsing the mouth after use is more commonly recommended with corticosteroid inhalers.
B. "I will use this medication early in the morning so I am not urinating all night." Ipratropium bromide does not significantly affect urination or the frequency of urination, as it primarily targets the respiratory system.
C. "I will make sure to use this in combination with a corticosteroid inhaler." Although it may be used in combination with corticosteroids, this is not specific to Ipratropium's side effects. This answer does not directly address side effect management.
D. "I will suck on hard candies to cope with dry mouth." A common side effect of Ipratropium bromide is dry mouth due to its anticholinergic properties. Sucking on hard candies is an appropriate way to manage this side effect.
Correct Answer is D
Explanation
A. Bradycardia: Bradycardia is not a common side effect of diphenhydramine. This medication primarily causes sedation and anticholinergic effects.
B. Hypertension: Hypertension is not commonly associated with diphenhydramine, which tends to have more sedative and anticholinergic side effects.
C. Bleeding: Bleeding is not a known side effect of diphenhydramine. It does not affect clotting mechanisms or platelet function.
D. Sedation: Sedation is a common side effect of diphenhydramine, which is an antihistamine with sedative properties. Clients should be advised about possible drowsiness and to avoid activities that require alertness, like driving, while taking it.