A patient develops anaphylactic shock in response to eating something that has caused an allergic response in the past. What physiologic changes should the nurse expect to observe in this patient? (Select all that apply.)
a. Weak pulse
b. Muscle pain
c. Stomach cramps
d. Nausea and vomiting
e. Drop in blood pressure
ANS: A, E
Anaphylactic shock is an allergic reaction, but massive in response. It is characterized by loss of plasma from capillaries as an effect of histamine and a sudden drop in the intravascular blood volume and blood pressure. B. C. D. Muscle pain, stomach cramps, and nausea and vomiting are not physiologic changes to anaphylactic shock.
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After shift change the nurse discovers that a client's IV heparin has been turned off at the IV controller. The amount of fluid left in the IV bag indicates that the client received half of the dose ordered
Which statement should be documented in the client's medical record? 1. IV heparin restarted. Physician notified. Client's vital signs unchanged. 2. IV heparin restarted at a rate to catch up dosage accidentally deleted. 3. IV heparin turned off by previous shift. Restarted. 4. IV heparin restarted and incident report completed.
A patient has sought medical attention because of a loss of different half-fields in the two eyes. Knowing the potential causes of this complaint, the nurse anticipates that the physician will order tests looking for
A) metal fragments in the eyes. B) hemorrhages in the capillaries of both eyes. C) an enlarging pituitary tumor. D) subarachnoid hemorrhage.
A mother has brought her 10-year-old to the emergency department (ED). The mother tells the triage nurse that the boy was stung by a bee about an hour ago
The mother explains to the nurse that it is very painful and looks swollen, red, and infected. What can the triage nurse teach the mother? A) The pain, redness, and swelling are part of the inflammatory process, but it is probably too early for an infection. B) Bee stings frequently cause infection, pain, and swelling, and, with treatment, the infection should begin to subside late today. C) The infection was probably caused by the stinger, which may still be in the wound. D) The mother's assessment is excellent and the ED doctor will probably prescribe antibiotics to fix the problem.
When you go to administer a client's dose of chlorpromazine (Thorazine), you note that he has developed a high fever and rapid heart rate. Which of the following actions would be BEST on your part?
a. Observe and give cool sponge baths. b. Give medication and repeat vital signs in 4 hours. c. Hold his medication and call the provider. d. Administer an anti-inflammatory prn drug.