A community nurse assesses a client, who has an allergy to bees, after a bee sting. The client's lips are swollen, and wheezes are audible. What is the priority action of the nurse?
a. Elevate the site and notify the client's next of kin.
b. Remove the stinger with tweezers and encourage rest.
c. Administer diphenhydramine (Benadryl) and apply ice.
d. Administer an EpiPen from the first aid kit and call 911.
D
The student's swollen lips indicate that anaphylaxis may be developing, and this is a medical emergency. 911 should be called immediately, and the client transported to the emergency de-partment as quickly as possible. If an EpiPen is available, it should be administered at the first sign of an anaphylactic reaction. The other answers do not provide adequate interventions to treat airway obstruction due to anaphylaxis.
You might also like to view...
A client in semi-Fowler's position has slipped down in bed and needs to be moved up. Which of these actions should the nurse take FIRST?
a. Ensure the bed is below waist level, and lower the head of the bed. b. Lower the side rails on the side where the nurse is standing. c. Ask the client to bend the knees, and place the feet flat on the bed. d. Change the bed linens.
The psychiatric clinical nurse specialist decides to use cognitive therapy techniques as she works
with a client with anorexia nervosa. Which statement by the nurse is consistent with the use of cognitive therapy principles? a. "What are your feelings about not eating the food that you prepare?" b. "You seem to feel much better about yourself when you eat something.". c. "It must be difficult to talk about private matters to someone you just met.". d. "Being thin doesn't seem to solve your problems; you're thin now and are still unhappy.".
A patient diagnosed with OCD paces up and down the corridor counting every tile. Select the nurse's best action
a. Offer to play cards with the patient in the dayroom. b. Ask the patient, "Why are you pacing and counting?" c. Take the patient's arm and escort the patient to a quiet area. d. Permit the patient to pace and count until feeling more comfortable.
The process through which a drug leaves the body through urine, sweat, feces, or other body secretions is called ________.
Fill in the blank(s) with the appropriate word(s).