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 A

Explanation

Choice A reason: Difficulty swallowing is a sign of anaphylaxis, which is a severe allergic reaction that can cause swelling of the throat and tongue, leading to airway obstruction and respiratory distress.

Choice B reason: Petechial rash on the abdomen is not a sign of anaphylaxis, but rather a sign of thrombocytopenia, which is a low platelet count that can cause bleeding under the skin.

Choice C reason: Hypertension is not a sign of anaphylaxis, but rather a sign of high blood pressure, which can be caused by various factors such as stress, pain, or kidney disease.

Choice D reason: Bilateral tinnitus is not a sign of anaphylaxis, but rather a sign of hearing loss or damage, which can be caused by exposure to loud noise, ear infection, or medication side effects.

A. "I have purchased a stoma cap I can use when needed." B. "I have my partner empty my pouch for me every morning." C. "I am embarrassed by the odor that comes from my ileostomy." D. "I miss going to my church meetings because of this ostomy."

Correct Answer is A

Explanation

Choice A reason: Purchasing a stoma cap that can cover and conceal the ileostomy when not in use indicates that the client is in the acceptance stage of grieving, as it shows that they have adapted to their new condition and are able to resume their normal activities and social interactions.

Choice B reason: Having their partner empty their pouch for them every morning indicates that the client is in the denial stage of grieving, as it shows that they are avoiding or rejecting their new condition and are dependent on others for their care.

Choice C reason: Being embarrassed by the odor that comes from their ileostomy indicates that the client is in the depression stage of grieving, as it shows that they have low self-esteem and negative feelings about their new condition and its impact on their quality of life.

Choice D reason: Missing going to their church meetings because of their ostomy indicates that the client is in the anger stage of grieving, as it shows that they have resentment and frustration about their new condition and its interference with their previous routines and values.

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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

Naxlex Comprehensive Predictor Exams

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