What is the major nursing concern for a child having an anaphylactic reaction?
a. Identifying the offending allergen
b. Ineffective breathing pattern
c. Increased cardiac output
d. Positioning to facilitate comfort
B
Laryngospasms resulting in ineffective breathing patterns are a life-threatening manifestation of anaphylaxis. The primary action is to assess airway patency, respiratory rate and effort, level of consciousness, oxygen saturation, and urine output. Determining the cause of an anaphylactic reaction is important to implement the appropriate treatment, but the primary concern is the airway. During anaphylaxis, the cardiac output is decreased. During the acute period of anaphylaxis, the nurse's primary concern is the child's breathing. Positioning for comfort is not a primary concern during a crisis.
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The nurse is monitoring a client with severe preeclampsia who is on IV magnesium sulfate. Which signs of magnesium toxicity should the nurse monitor for? (Select all that apply.)
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