Author Question: A nurse assesses a client admitted with a brown recluse spider bite. Which priority assessment ... (Read 67 times)

D2AR0N · **on:** Jun 25, 2018

A nurse assesses a client admitted with a brown recluse spider bite. Which priority assessment should the nurse perform to identify complications of this bite?

a. Ask the client about pruritus at the bite site.
b. Inspect the bite site for a bluish purple vesicle.
c. Assess the extremity for redness and swelling.
d. Monitor the client's temperature every 4 hours.

Question 2

While on a camping trip, a nurse cares for an adult client who had a drowning incident in a lake and is experiencing agonal breathing with a palpable pulse. Which action should the nurse take first?

a. Deliver rescue breaths.
b. Wrap the client in dry blankets.
c. Assess for signs of bleeding.
d. Check for a carotid pulse.

ghepp · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: D
Fever and chills indicate systemic toxicity, which can lead to hemolytic reactions, kidney failure, pulmonary edema, cardiovascular collapse, and death. Assessing for a fever should be the nurse's priority. All other symptoms are normal for a brown recluse bite and should be assessed, but they do not provide information about complications from the bite, and therefore are not the priority.

Answer to Question 2

ANS: A
In this emergency situation, the nurse should immediately initiate airway clearance and ventilator support measures, including delivering rescue breaths.