A client is given a dose of ketorolac (Toradol), a nonsteroidal anti-inflammatory drug for complaints of abdominal pain. Ten minutes after receiving the medication, the client's eyes, lips, and face begin to swell, and the nurse hears stridor
What priority measure should the nurse prepare to do? A) Intubate the client.
B) Perform an electrocardiogram (ECG).
C) Assess the client's vital signs.
D) Administer epinephrine.
D
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Anaphylaxis is a rapid and profound type I hypersensitivity response. A massive release of histamine causes vasodilation; increased capillary permeability; angioneurotic edema (acute swelling of the face, neck, lips, larynx, hands, feet, genitals, and internal organs); hypotension; and bronchoconstriction. A nurse must administer 0.2 mg of epinephrine subcutaneously to a client experiencing a severe allergic reaction. It is outside of the nurse's practice to intubate a patient. Performing an ECG and assessing the vital signs delays the treatment of the client and can have negative outcomes.
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a. Administer the drug through a separate IV line. b. Infuse pantoprazole using an IV pump. c. Keep the drug in its original brown bag. d. Take vital signs frequently during infusion. e. Use an in-line IV filter when infusing.
The nurse working in a pediatric clinic is caring for a young child whose mother reports the child has drainage from the eye and cannot see in the morning because the child's eyes are crusted shut
After the doctor diagnosis conjunctivitis, the nurse teaches the mother to do which of the following? 1. Use boric acid on a washcloth to clean the eye. 2. Use sterile gloves to clean the eye with cold tap water. 3. Moisten a cotton ball to remove secretions. 4. Clean the eyes from the outer to inner canthus.
For a client whose resting pulse rate is 71 beats/min, the nurse would check the client's pulse rate to ensure that during post-MI activities, the client's heart rate does not exceed
a. 89 beats/min. b. 96 beats/min. c. 101 beats/min. d. 112 beats/min.
The client is being treated with digoxin. She tells the nurse that she frequently self-medicates her depression with St. John's wort. What is the nurse's highest priority instruction to the client?
a. Take the St. John's wort; it will have no effect on the digoxin. b. Do not take St. John's wort; it will cause a toxic reaction to the digoxin. c. Do not take St. John's wort; it decreases the effectiveness of the digoxin. d. Take the St. John's wort; it will enhance the effect of the digoxin.