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?"
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Urinating before and after sexual intercourse can help flush out any bacteria that may have entered the urinary tract during sexual activity, and prevent them from causing an infection.
Choice B reason: Increasing milk consumption to make the urine more alkaline is not a recommended instruction, as it may increase the risk of developing kidney stones or calcium deposits in the urinary tract.
Choice C reason: Emptying the bladder at least every 4 hours is a good practice, but not sufficient to prevent urinary tract infections. The nurse should also advise the client to drink plenty of fluids, especially water, to dilute the urine and flush out bacteria.
Choice D reason: Using vaginal douche once a week is not a recommended instruction, as it may alter the normal flora of the vagina and increase the risk of infection. The nurse should advise the client to avoid using any products that may irritate the genital area, such as perfumed soaps, sprays, or powders.
Choice E reason: Drinking cranberry juice daily is not a proven method to prevent urinary tract infections, although some studies suggest that it may have some benefits. The nurse should inform the client that cranberry juice may interact with some medications, such as warfarin, and that it may also increase the acidity of the urine, which can cause discomfort or burning sensation.
Correct Answer is C
Explanation
Choice A reason: Discouraging reminiscing about the past is not a helpful strategy for a client who has dementia and confusion. Reminiscing can stimulate memory, enhance mood, and promote social interaction.
Choice B reason: Asking open-ended questions that encourage the client to express their feelings is not appropriate for a client who has dementia and confusion. Open-ended questions can increase frustration and anxiety for the client who may have difficulty finding words or recalling events. The nurse should use simple, direct, and closed-ended questions instead.
Choice C reason: Using holiday decorations to provide orientation to the time of the year is a beneficial action for a client who has dementia and confusion. Holiday decorations can help the client recognize familiar cues and reduce disorientation.
Choice D reason: Encouraging multiple family members to visit the client at the same time is not advisable for a client who has dementia and confusion. Multiple visitors can overwhelm and agitate the client who may have trouble recognizing faces or voices. The nurse should limit the number of visitors and ensure they are calm and supportive.
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