A client is in the hospital and receiving IV antibiotics. When the nurse answers the client's call light, the client presents an appearance as shown below:
What action by the nurse takes priority?
a.
Administer epinephrine 1:1000, 0.3 mg IV push immediately.
b.
Apply oxygen by facemask at 100 and a pulse oximeter.
c.
Ensure a patent airway while calling the Rapid Response Team.
d.
Reassure the client that these manifestations will go away.
Question 2A nurse has educated a client on an epinephrine auto-injector (EpiPen). What statement by the client indicates additional instruction is needed?
a. I don't need to go to the hospital after using it.
b. I must carry two EpiPens with me at all times.
c. I will write the expiration date on my calendar.
d. This can be injected right through my clothes.
Question 3A client with Sjgren's syndrome reports dry skin, eyes, mouth, and vagina. What nonpharmacologic comfort measure does the nurse suggest?
a. Frequent eyedrops
b. Home humidifier
c. Strong moisturizer
d. Tear duct plugs
Question 4A client is receiving plasmapheresis as treatment for Goodpasture's syndrome. When planning care, the nurse places highest priority on interventions for which client problem?
a. Reduced physical activity related to the disease's effects on the lungs
b. Inadequate family coping related to the client's hospitalization
c. Inadequate knowledge related to the plasmapheresis process
d. Potential for infection related to the site for organism invasion
Question 5A client calls the clinic to report exposure to poison ivy and an itchy rash that is not helped with over-the-counter antihistamines. What response by the nurse is most appropriate?
a. Antihistamines do not help poison ivy.
b. There are different antihistamines to try.
c. You should be seen in the clinic right away.
d. You will need to take some IV steroids.
Question 6A nurse suspects a client has serum sickness. What laboratory result would the nurse correlate with this condition?
a. Blood urea nitrogen: 12 mg/dL
b. Creatinine: 3.2 mg/dL
c. Hemoglobin: 8.2 mg/dL
d. White blood cell count: 12,000/mm3
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