Practice Question
Fifteen minutes after receiving sulfamethoxazole-trimethoprim (SMZ-TMP), the client reports a burning sensation over the abdomen, chest, and groin. Which intervention is most important for the nurse to implement?
Answer Choices:
Correct Answer:
Auscultate lung sounds for wheezing.
Rationale:
🟦 A burning sensation over the abdomen, chest, and groin soon after receiving SMZ-TMP suggests a potential anaphylactic reaction.
🟦 Early airway assessment is critical because anaphylaxis can rapidly progress to bronchospasm and airway obstruction.
🟦 Wheezing is a key indicator of respiratory compromise and must be checked immediately.
🟦 Rapid identification allows timely administration of epinephrine, oxygen, or antihistamines if needed.
🟦 Airway and breathing follow the ABCs priority, making respiratory assessment the most urgent action.
Check neurological vital signs
🟦 Neurological checks do not address the immediate danger of airway narrowing.
🟦 Delaying respiratory assessment could allow progression to severe anaphylaxis.
Review the client’s list of drug allergies
🟦 Reviewing allergies is important but does not help in the acute moment when symptoms are occurring.
🟦 The priority is assessing for airway involvement, not retrospective information.
Document findings in the medical record
🟦 Documentation occurs after emergency assessment and stabilization.
🟦 Focusing on charting first delays critical evaluation of airway compromise.
Want to practice more questions like this?
This question is from HESI EXIT 2025 Exam.. which contains 126 questions.
More Questions from This Exam
The school nurse is implementing standards to manage students and provide a safe and healthy school setting. Which action is most important for the nurse to implement?
Answer Choices:
Which environmental factor is most significant when planning care for a client with osteocalcin?
Answer Choices:
A client receives a new prescription for zafirlukast. Prior to administering the medication, the nurse should review the electronic medical record for which condition?
Answer Choices:
A client on the psychiatric unit is making sexual advances toward a nurse. Which action should this nurse implement first?
Answer Choices:
An older adult client is admitted with the medical diagnosis of possible cerebrovascular accident (CVA). The client has facial paralysis and cannot move the left side of the body. When entering the room, the nurse finds the client's spouse tearful and trying unsuccessfully to give the client a drink of water. Which action should the nurse take?
Answer Choices:
Question Details
- Category: RN Nursing Exam(s)
- Subcategory: HESI-Exit Exam(s)
- Domain: HESI Exit Exam(s)~2025
- Answer Choices: 4