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 B

Explanation

Choice A reason: Staying nearby can provide comfort and support is not an appropriate response, as it does not acknowledge or validate the partner's feelings of grief and loss. The nurse should listen empathetically and encourage the partner to express their emotions.

Choice B reason: I can understand your feelings of sadness is an appropriate response, as it shows empathy and compassion for the partner's situation and allows them to feel heard and understood.

Choice C reason: I will be positive and optimistic for you is not an appropriate response, as it implies that the partner's feelings are negative or inappropriate and that they need to be changed or fixed. The nurse should respect and accept the partner's feelings without judging or minimizing them.

Choice D reason: You should try to be strong for him is not an appropriate response, as it places pressure and expectations on the partner and discourages them from showing their true feelings. The nurse should support and empower the partner without imposing their own values or beliefs.

A. Cover the client with a warm blanket. B. Increase the IV fluid rate. C. Reassure the client. D. Compare the reading to the preoperative value.

Correct Answer is D

Explanation

Choice D: Comparing the reading to the preoperative value is the first action that the nurse should take because it can help determine if the client's blood pressure is normal for them or if it indicates hypotension, which can be a sign of hemorrhage, shock, or infection.

Choice a is not correct because covering the client with a warm blanket is not the first action that the nurse should take, but rather an intervention that can help prevent hypothermia and shivering, which can increase oxygen demand and blood loss.

Choice b is not correct because increasing the IV fluid rate is not the first action that the nurse should take, but rather an intervention that can help restore fluid volume and blood pressure, if indicated by other data and prescribed by the provider.

Choice c is not correct because reassuring the client is not the first action that the nurse should take, but rather an intervention that can help reduce anxiety and stress, which can affect blood pressure and heart rate.

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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?

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