what is the first intervention for a patient who is experiencing anaphylactic shock
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Nursing Elites

ATI RN

ATI RN Comprehensive Exit Exam

1. What is the first intervention for a patient experiencing anaphylactic shock?

Correct answer: A

Rationale: The correct answer is to administer epinephrine. Epinephrine is the first-line treatment for anaphylactic shock as it helps reverse the severe allergic reaction by constricting blood vessels, increasing heart rate, and opening airways for improved breathing. Oxygen (Choice B) can be administered after epinephrine to support oxygenation. Corticosteroids (Choice C) may be used to prevent a biphasic reaction but are not the initial intervention. Antihistamines (Choice D) can help with itching and hives but do not address the life-threatening symptoms of anaphylaxis.

2. A nurse is assessing a client who is receiving a continuous heparin infusion. Which of the following findings should the nurse report to the provider?

Correct answer: D

Rationale: The correct answer is D because an INR of 1.0 is below the therapeutic range for clients receiving heparin, indicating a potential need for dosage adjustment. Platelet count (choice A) within normal range, aPTT (choice B) within therapeutic range, and hemoglobin level (choice C) are not directly related to the monitoring of heparin therapy and would not require immediate reporting to the provider.

3. A healthcare professional is preparing to administer an IV bolus of morphine to a client. Which of the following actions should the healthcare professional take first?

Correct answer: A

Rationale: Correct Answer: Checking the client's respiratory rate is the priority before administering morphine because morphine can depress respiration. This action helps the healthcare professional assess the client's baseline respiratory status and detect any potential respiratory depression that may be exacerbated by morphine. Choice B, administering naloxone, is incorrect because naloxone is used as an antidote for opioid overdose and not routinely administered before giving morphine. Choice C, checking the client's pain level, is important but not the first action to take before administering morphine. Choice D, assessing the client's blood pressure, is also important but not the initial priority compared to evaluating respiratory status when preparing to administer morphine.

4. A nurse is planning care for a client who is experiencing acute mania. What intervention should the nurse include?

Correct answer: A

Rationale: The correct answer is A: Encourage the client to take frequent rest periods. During acute mania, individuals often experience high levels of energy, decreased need for sleep, and increased activity levels. Encouraging the client to take frequent rest periods can help prevent exhaustion and promote better self-regulation. Choice B is incorrect because withdrawing TV privileges may not be directly related to managing acute mania. Choice C is incorrect as placing the client in seclusion can exacerbate feelings of anxiety and agitation. Choice D is incorrect as spending time in the day room may not address the need for rest and relaxation that is crucial during acute mania.

5. While caring for a client receiving a blood transfusion who reports chills, which action should the nurse take first?

Correct answer: A

Rationale: The correct action for the nurse to take first when a client reports chills during a blood transfusion is to stop the transfusion. Chills can indicate a transfusion reaction, which is a potentially serious situation. Stopping the transfusion immediately is crucial to prevent further complications. Administering acetaminophen or checking the client's blood pressure can come after ensuring the safety of the client by stopping the transfusion. Notifying the provider is important, but the immediate priority is to stop the transfusion.

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