Kenneth Bronson (Pneumonia)

Epinephrine is administered for Kenneth Bronson's acute anaphylactic reaction. Which of the following does the nurse know is a possible side effect of this drug?

Tachycardia Rationale: Tachycardia is one possible cardiovascular adverse effect of epinephrine.

Which of the following represent initial signs and symptoms of a patient in respiratory distress? (Select all that apply.) A. Dyspnea B. Fever C. Tachypnea D. Hypoxemia E. Cyanosis

A. Dyspnea C. Tachypnea D. Hypoxemia Rationale: Dyspnea and tachypnea accompanied by low oxygen in the blood are associated with respiratory distress. Cyanosis is a very late indicator of hypoxia to the tissues. Fever is an indication of infection.

The nurse administering diphenhydramine understands that the medication falls under which of the following categories for the treatment of an anaphylactic reaction?

Antihistamine Rationale: Diphenhydramine (Benadryl) is an antihistamine used to block the histamine released in the immune response with anaphylaxis.

When a patient develops respiratory distress, what is the appropriate first action for the nurse to take to address this specific concern?

Assess airway, breathing, circulation and auscultate the lungs Rationale: When a patient is in respiratory distress it is important to determine the cause so appropriate measures to treat the patient can be started. Assessing the airway, breathing, and circulation are the basic first steps. Auscultating the lungs help to further delineate what the potential cause and treatment will be.

What is the priority action by the nurse when a patient experiences sudden respiratory distress? A. Place an intravenous line B. Assess the airway C. Call the provider D. Lower the head of bed

B. Assess the airway Rationale: The priority action is to assess the airway. Raising the head of bed will improve lung expansion. The provider should be notified and IV line may be needed, but assessing the patient is the priority.

The nurse is auscultating lung sounds. What lung sound is associated with narrowing of the airway? A. Bronchophony B. Wheezes C. Crackles D. Egophony

B. Wheezing Rationale: Wheezing is a high-pitched, musical sound associated with airway narrowing. Crackles are described as a popping sound heard during inspiration from fluid or delayed opening of collapsed alveoli. Bronchophony or egophony can be auscultated when there is increased lung density from pneumonia and pulmonary edema.

The nurse is assessing the lungs of a patient diagnosed with pneumonia. Which of the following would be expected upon auscultation?

Bronchial breath sounds Rationale: Bronchial breath sounds occur in consolidation, such as pneumonia. Egophony may occur in patients diagnosed with pleural effusion. Absent breath sounds occurs in pneumothorax. Wheezes are associated with bronchial wall oscillation and changes in airway diameter.

Which medication was administered to Mr. Bronson to decrease inflammation?

Methylprednisolone Rationale: Methylprednisolone is a corticosteroid used to decrease inflammation. Albuterol and epinephrine cause bronchodilation. Acetaminophen is used to treat the fever from pneumonia

The nurse understands that which of the following is the most common cause of anaphylaxis?

Penicillin Rationale: Penicillin is the most common cause of anaphylaxis and accounts for about 75% of fatal anaphylactic reactions in the United States each year. Substances that most commonly cause anaphylaxis include foods, medications, insect stings, and latex. Opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and radiocontrast a

Once the patient is stabilized after an anaphylactic reaction, what information would be most essential for the nurse to include with patient and family follow-up teaching?

What caused the event and how to prevent an anaphylactic reaction Rationale: It will be important for the patient and family to know what caused the anaphylactic reaction and how to prevent it from happening in the future. They should also receive instruction on the proper use of a preloaded epinephrine syringe.

What risk factor does the nurse recognize that Kenneth Bronson had related to pneumonia?

Smoking Rationale: Smoking is a risk factor for pneumonia; cigarette smoke disrupts both mucociliary and macrophage activity. Although staphylococcal pneumonia has been noted after epidemics of influenza, Kenneth Bronson did not have this particular risk factor.

The nurse should include which statement when providing education once the patient is first stabilized after an anaphylactic reaction?

"You will be closely monitored since there is a chance of a delayed reaction." Rationale: The patient requires continued observation and monitoring because of the risk for a "rebound" or delayed immune reaction. The patient will not be immediately discharged once stable. Patients who have experienced an anaphylactic reaction should receive a prescription for preloaded syringes of epinephrine. Oxygen therapy is individualized and based on SpO2 levels and blood gases. Intubation is not mandated if the patient's respiratory status is stable.

The patient experiencing an anaphylactic reaction may experience which of the following signs and symptoms? (Select all that apply.) A. Bronchospasm B. Pallor C. Pruritus D. Dyspnea E. Laryngeal edema

A. Bronchospasm C. Pruritus D. Dyspnea E. Laryngeal edema Rationale: Mild systemic reactions consist of peripheral tingling, warmth, a sensation of fullness in the mouth and throat, nasal congestion, periorbital swelling, pruritus, sneezing, and tearing of the eyes. Moderate systemic reactions may include flushing and anxiety in addition to any of the milder symptoms. More serious reactions include bronchospasm, laryngeal edema, severe dyspnea, cyanosis, and hypotension. Dysphagia (difficulty swallowing), abdominal cramping, vomiting, diarrhea, and seizures can also occur. Cardiac arrest and coma may follow.

When a patient presents to the emergency department with pneumonia, which signs and symptoms would the nurse expect the patient to exhibit? (Select all that apply.) A. Fever B. Orthopnea C. Dyspnea D. Night sweats E. Fatigue

A. Fever B. Orthopnea C. Dyspnea E. Fatigue Rationale: Fever is present with the infection. Patients will exhibit dyspnea, preferring to be propped up or sitting up due to orthopnea (shortness of breath when reclining or supine). The patient is fatigued from the work of breathing.

A patient experiencing respiratory distress at home from pneumonia is brought to the hospital and upon presentation requires intubation. How would the nurse classify this type of pneumonia? A. Ventilator-associated pneumonia B. Health care-associated pneumonia C. Community-acquired pneumonia D. Hospital-acquired pneumonia

C. Community-acquired pneumonia Rationale: Community-acquired pneumonia (CAP) is pneumonia occurring in the community or within less than 48 hours of hospital admission. Health care-associated pneumonia (HCAP) occurs in a nonhospitalized patient with extensive health care contact. Hospital-acquired pneumonia (HAP) occurs 48 hours or more after hospital admission. Ventilator-associated pneumonia (VAP) is a type of HAP that develops 48 hours or more after intubation.

Which of the following is used intravenously to maintain blood pressure in a patient experiencing hypotension during an anaphylactic reaction? (Select all that apply.)

Epinephrine, Normal saline Rationale: A bolus of normal saline is given for hypotension. An epinephrine IV drip will increase blood pressure. Dextrose is not given as a bolus. Aminophylline and albuterol are bronchodilators.