A nurse administered a dose of penicillin to a client 30 min ago. The client reports dizziness and wheezes when breathing. Which of the following questions by the nurse is the highest priority?

"Are you having difficulty breathing?"

"I'm going to take your heart rate."

"I need to give you diphenhydramine."

"Do you have any allergies to medications?"

Answer and Explanation

The Correct Answer is A

Choice A reason: Asking the client if they are having difficulty breathing is the highest priority question, as it can assess the severity of their allergic reaction to penicillin and the risk of anaphylaxis, which is a life-threatening condition that can cause airway obstruction and respiratory failure.

Choice B reason: Taking the client's heart rate is not a question, but an action that can be done after asking the client about their breathing status. The heart rate can indicate the presence of tachycardia or arrhythmia, which are signs of cardiovascular compromise due to an allergic reaction.

Choice C reason: Telling the client that they need to receive diphenhydramine is not a question, but an action that can be done after asking the client about their breathing status. Diphenhydramine is an antihistamine drug that can reduce the symptoms of an allergic reaction, such as itching, swelling, or wheezing.

Choice D reason: Asking the client if they have any allergies to medications is not a high priority question, as it can be done before administering penicillin or after stabilizing the client's condition. Knowing the client's allergy history can help prevent future adverse reactions and guide appropriate treatment choices.Question 42

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Correct Answer is C

Explanation

Choice A: This is incorrect. The Sims' position is not used for a colposcopy, which is a procedure that examines the cervix with a magnifying device. The client should be placed in the lithotomy position, which involves lying on the back with the legs spread and supported by stirrups.

Choice B: This is incorrect. The nurse should not insert a tampon following the procedure, as this can introduce bacteria and cause infection. The nurse should advise the client to use sanitary pads instead.

Choice C: This is correct. The nurse should instruct the client to avoid sexual intercourse until the cervix is healed, which can take up to a week. Sexual intercourse can cause bleeding, pain, and infection.

Choice D: This is incorrect. The nurse should not reinforce teaching that the procedure involves dilation of the cervix, as this is not true. A colposcopy does not require dilation of the cervix, unlike some other procedures such as endometrial biopsy or hysteroscopy.

A. Blood glucose 98 mg/dL B. BUN 18 mg/dL C. Hemoglobin 8.6 g/dL D. Potassium 3.5 mEq/L

Correct Answer is C

Explanation

Choice C Hemoglobin 8.6 g/dL indicates the nurse should notify the provider because it is below the normal range of 12 to 18 g/dL and suggests blood loss or anemia, which can impair oxygen delivery to tissues and affect wound healing.

Choice a is not correct because blood glucose 98 mg/dL does not indicate the nurse should notify the provider because it is within the normal range of 70 to 110 mg/dL and does not indicate hyperglycemia or hypoglycemia, which can affect recovery.

Choice b is not correct because BUN 18 mg/dL does not indicate the nurse should notify the provider because it is within the normal range of 10 to 20 mg/dL and does not indicate renal impairment or dehydration, which can affect fluid and electrolyte balance.

Choice d is not correct because potassium 3.5 mEq/L does not indicate the nurse should notify the provider because it is within the normal range of 3.5 to 5 mEq/L and does not indicate hypokalemia or hyperkalemia, which can affect cardiac function and muscle contraction.

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A nurse administered a dose of penicillin to a client 30 min ago. The client reports dizziness and wheezes when breathing. Which of the following questions by the nurse is the highest priority?

Nursing Test Bank

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