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    Kenneth Bronson experienced respiratory distress due to an anaphylactic reaction. The nurse assessed the airway, administered epinephrine, diphenhydramine, albuterol, ranitidine, and methylprednisolone to address the reaction. Vital signs, IV access, and lung sounds were also assessed. The patient was educated on anaphylactic reactions and the importance of follow-up due to the risk of delayed reactions.

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    Kenneth Bronson experienced respiratory distress due to an anaphylactic reaction. The nurse assessed the airway, administered epinephrine, diphenhydramine, albuterol, ranitidine, and methylprednisolone to address the reaction. Vital signs, IV access, and lung sounds were also assessed. The patient was educated on anaphylactic reactions and the importance of follow-up due to the risk of delayed reactions.

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    170 views2 pages

    Clinical 2

    Uploaded by

    Jonathan
    Kenneth Bronson experienced respiratory distress due to an anaphylactic reaction. The nurse assessed the airway, administered epinephrine, diphenhydramine, albuterol, ranitidine, and methylprednisolone to address the reaction. Vital signs, IV access, and lung sounds were also assessed. The patient was educated on anaphylactic reactions and the importance of follow-up due to the risk of delayed reactions.

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    of 2

    vSim: 80%, Kenneth Bronson

    Pre-quiz:
    1. What is the priority action by the nurse when a patient experiences sudden
    respiratory distress? – Assess the airway
    2. 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? – Community-Acquired Pneumonia
    3. Which of the following represent initial signs and symptoms of a patient in
    respiratory distress? (Select all that apply.) – Dyspnea, Tachy, Hypoxemia
    4. The nurse is auscultating lung sounds. What lung sound is associated with
    narrowing of the airway? - Wheezes
    5. 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.)
    – Fever, Orthopnea, Dyspnea, Fatigue
    6. The patient experiencing an anaphylactic reaction may experience which of the
    following signs and symptoms? (Select all that apply.) – Bronchospasm, Pruritus,
    Dyspnea, Laryngeal edema

    vSim:
    Safety Measures:
    Wash hands
    Identify patient
    Ask about allergies
    Communication/Pain Assessment
    Communication/Current Illness
    Communication/Past Medical History
    Communication/Orientation
    Assessment/Auscultate
    Assessment/Vital signs
    NIBP
    Assessment/Neuro
    Drugs & IV Management/Manage IV Access & Active Drugs
    Assess IV site
    Flush IV
    Drugs: Cefetriaxone/IV Pump
    Provider’s Order
    Administer
    Flush IV
    STOP INFUSION OF CEF
    Call Provider
    Administered Epi 1:1000, 0.5 mg
    Diphen – providers order, flush, administer, flush
    Albuterol – nebulizer
    Ranitidine
    Methylprednisone
    **ATTACH 3-Lead ECG monitoring
    Call provider
    Interventions/Comfort measures
    Raise bed
    **Pt EDUCATION

    Post-quiz:
    1. 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
    2. The nurse understands that which of the following is the most common cause of
    anaphylaxis? - Penicillin
    3. 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
    4. The nurse administering diphenhydramine understands that the medication falls
    under which of the following categories for the treatment of an anaphylactic
    reaction? – Antihistamine
    5. 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."
    6. Which medication was administered to Mr. Bronson to decrease inflammation? -
    Methylprednisolone
    7. What risk factor does the nurse recognize that Kenneth Bronson had related to
    pneumonia? - Smoking
    8. 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
    9. The nurse is assessing the lungs of a patient diagnosed with pneumonia. Which of
    the following would be expected upon auscultation? - Bronchial breath sounds
    10. 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

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