Here are three NCLEX-style review questions:
Question 1 and 2 pertain to the same patient and scenario.
1. You are a nurse working in the emergency department. During your shift, a 16-year-old boy was rushed into the ER and is having an anaphylactic reaction. Which of the following signs and symptoms is most alarming and requires immediate intervention?
A. Patient has vomited several times before coming to ER, and is experiencing bad abdominal cramps
B. Patient says his body is very itchy, and you noticed there are red patches on his skin
C. Patient is very anxious and states that he has tight throat, and you heard wheezing when auscultating breath sounds
D. Patient has a decreased level of consciousness and isn't responding to external stimuli and his blood pressure is 75/46
2. Which of the following responses would be most appropriate for the nurse to make?
A. Inject EpiPen right away and call the team. Ask the patient to stay in the hospital even when symptoms have disappeared.
B. Give patient a glass of water to drink, as dehydration may worsen the symptoms and cause anaphylactic shock
C. Instruct the patient to experiment with different potential allergens at home, so that he knows which allergen can cause anaphylaxis and should avoid in the future
D. Inform the patient and family that anaphylactic reactions are rare and totally random and re-exposure to the same allergen will not cause an anaphylactic reaction
3. Which of the following statement(s) is/are true with regard to epinephrine? (Select all that apply)
A. Epinephrine is currently the first-line treatment for anaphylaxis used in hospital settings
B. It should be injected by the subcutaneous route in the outer thigh
C. It acts as a vasoconstrictor
D. After epinephrine injection, it is best to lie on your back with lower limbs elevated
E. The epinephrine injection can be repeated once or twice at 5–15 min intervals in patients who do not respond to the first dose
Question 1 and 2 pertain to the same patient and scenario.
1. You are a nurse working in the emergency department. During your shift, a 16-year-old boy was rushed into the ER and is having an anaphylactic reaction. Which of the following signs and symptoms is most alarming and requires immediate intervention?
A. Patient has vomited several times before coming to ER, and is experiencing bad abdominal cramps
B. Patient says his body is very itchy, and you noticed there are red patches on his skin
C. Patient is very anxious and states that he has tight throat, and you heard wheezing when auscultating breath sounds
D. Patient has a decreased level of consciousness and isn't responding to external stimuli and his blood pressure is 75/46
2. Which of the following responses would be most appropriate for the nurse to make?
A. Inject EpiPen right away and call the team. Ask the patient to stay in the hospital even when symptoms have disappeared.
B. Give patient a glass of water to drink, as dehydration may worsen the symptoms and cause anaphylactic shock
C. Instruct the patient to experiment with different potential allergens at home, so that he knows which allergen can cause anaphylaxis and should avoid in the future
D. Inform the patient and family that anaphylactic reactions are rare and totally random and re-exposure to the same allergen will not cause an anaphylactic reaction
3. Which of the following statement(s) is/are true with regard to epinephrine? (Select all that apply)
A. Epinephrine is currently the first-line treatment for anaphylaxis used in hospital settings
B. It should be injected by the subcutaneous route in the outer thigh
C. It acts as a vasoconstrictor
D. After epinephrine injection, it is best to lie on your back with lower limbs elevated
E. The epinephrine injection can be repeated once or twice at 5–15 min intervals in patients who do not respond to the first dose
Answers:
1. Correct answer: D
Patient is unconscious and in a hypotensive state. In other options, patient is still conscious and able to make conversation.
2. Correct answer: A
Epinephrine is the first line treatment for anaphylaxis. Symptoms can disappear and then return within a few hours, even with treatment. Therefore, the patient should be encouraged to stay in the hospital for a period of observation after any anaphylactic reaction.
B is wrong, if a patient is having trouble breathing, oral administration of medication is unsafe.
C and D are wrong, re-exposure to allergen can cause serious anaphylaxis.
3. Correct answers: A, C, D, and E.
B is in correct because epinephrine should be injected by the intramuscular route in the outer thigh. A, C, D, and E are correct, refer to treatment for details.
1. Correct answer: D
Patient is unconscious and in a hypotensive state. In other options, patient is still conscious and able to make conversation.
2. Correct answer: A
Epinephrine is the first line treatment for anaphylaxis. Symptoms can disappear and then return within a few hours, even with treatment. Therefore, the patient should be encouraged to stay in the hospital for a period of observation after any anaphylactic reaction.
B is wrong, if a patient is having trouble breathing, oral administration of medication is unsafe.
C and D are wrong, re-exposure to allergen can cause serious anaphylaxis.
3. Correct answers: A, C, D, and E.
B is in correct because epinephrine should be injected by the intramuscular route in the outer thigh. A, C, D, and E are correct, refer to treatment for details.