Author Question: A patient arrives in the emergency department after developing a rash, runny nose, and sneezing ... (Read 52 times)

nramada · **on:** Jul 23, 2018

A patient arrives in the emergency department after developing a rash, runny nose, and sneezing after eating strawberries. What action will the nurse expect to take first?

a. Administer diphenhydramine.
b. Administer epinephrine.
c. Assess for urinary retention.
d. Assess heart rate, respiratory rate, and lung sounds.

Question 2

The nurse is caring for a patient who is receiving diphenhydramine. The nurse notes that the patient has not voided for 12 hours. What action will the nurse take?

a. Encourage the patient to drink more fluids.
b. Evaluate the bladder to check for distension.
c. Request an order for an intravenous fluid bolus.
d. Request an order for urinary catheterization.

parker125 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: D
The patient probably has a food allergy, since eating strawberries is the precipitating event. The nurse should assess cardiac and respiratory status to determine whether the patient is developing an anaphylactic reaction. Diphenhydramine will be given for mild allergic symptoms of rash, runny nose, and sneezing, but epinephrine must be given for anaphylaxis. Urinary retention is a side effect of diphenhydramine and will be assessed if diphenhydramine is given.

Answer to Question 2

ANS: B
Diphenhydramine has anticholinergic effects, including urinary retention. The nurse should assess for bladder distension to determine if this is the case. Encouraging the patient to drink more fluids or giving intravenous fluids may be necessary if the patient has oliguria secondary to dehydration. Urinary catheterization is not indicated until urinary retention has been identified.