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 teaching a group of newly licensed nurses about measures to take when caring for a client who is on contact precautions. Which of the following should the nurse include in the teaching?

Correct answer: C

Rationale: The correct measure to include when caring for a client on contact precautions is to wear gloves when providing care. Gloves help prevent the spread of infection and cross-contamination. Choice A is incorrect because the protective gown should be removed before leaving the client's room to prevent the spread of pathogens. Choice B is incorrect as clients on contact precautions should be in a room with negative pressure to prevent the spread of airborne contaminants. Choice D is incorrect as wearing a mask when changing linens is not specifically required for contact precautions.

3. A nurse is preparing to administer an immunization to a 6-month-old infant. Which of the following actions should the nurse take to reduce pain at the injection site?

Correct answer: D

Rationale: Administering a local anesthetic at the injection site can help reduce pain during immunizations in infants. Options A, B, and C are incorrect. Administering the immunization in the deltoid muscle may not provide pain relief. Applying a cold compress or pressure to the injection site is not as effective as using a local anesthetic to reduce pain.

4. A healthcare provider is teaching a client who has a new diagnosis of hypertension about dietary management. Which of the following foods should the healthcare provider instruct the client to avoid?

Correct answer: C

Rationale: The correct answer is C. Bacon is high in sodium, which can elevate blood pressure levels. Clients with hypertension should avoid high-sodium foods like bacon to help manage their blood pressure. Choices A, B, and D are healthier options compared to bacon and can be included in a balanced diet for someone with hypertension. Bananas are a good source of potassium, which can help in managing blood pressure. Carrots are low in sodium and high in fiber, making them a heart-healthy choice. Chicken breast is a lean protein option that is beneficial for individuals with hypertension.

5. A nurse is planning care for a client who has a nasogastric tube for enteral feedings. Which of the following interventions should the nurse include to prevent aspiration?

Correct answer: C

Rationale: Elevating the head of the bed to 45 degrees during feedings is the correct intervention to prevent aspiration in clients with a nasogastric tube. This position helps reduce the risk of regurgitation and subsequent aspiration of stomach contents into the lungs. Flushing the tube with water before feedings (Choice A) is not necessary for preventing aspiration. Checking for gastric residuals (Choice B) helps monitor feeding tolerance but does not directly prevent aspiration. Placing the client in the left lateral position (Choice D) is not specifically indicated for preventing aspiration in a client with a nasogastric tube.

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