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 D

Explanation

Choice A: This is incorrect because positioning the bedside table close to the client can help them reach their personal items and reduce the need to get out of bed.

Choice B: This is incorrect because keeping the client's bed in the low position can prevent injuries in case of a fall and make it easier for the client to get in and out of bed.

Choice C: This is incorrect because attaching the call light to the side rail of the client's bed can ensure that the client can access it easily and call for assistance when needed.

Choice D: This is correct because instructing the client to wear their own socks to the bathroom can increase the risk of slipping and falling. The client should wear non-skid footwear or slippers when walking.

A. Replace the unit when the drainage chamber is full. B. Pin the tubing to the client's bed sheets. C. Monitor for at least 150 mL of drainage every hour. D. Clamp the tube for 30 min every 8 hr.

Correct Answer is A

Explanation

The correct answer is A:

Choice A reason:

Replace the unit when the drainage chamber is full. This ensures continuous, effective drainage. A full chamber cannot collect more fluid, risking system compromise and patient safety.

Choice B reason:

Pinning the tubing to the bed sheets is incorrect because it can cause kinks in the tubing, leading to obstruction of drainage and potential complications.

Choice C reason:

Monitoring for at least 150 mL of drainage every hour is not a standard practice. Normal chest tube drainage is variable; excessive drainage, such as 150 mL/hour, could indicate a serious condition like hemorrhage.

Choice D reason:

Clamping the tube routinely for 30 minutes every 8 hours is not recommended. Clamping may be done during tube removal or to check for air leaks but doing so routinely can lead to tension pneumothorax.

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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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