A nurse administered a dose of penicillin to a client 30 minutes ago. The client reports that she has hives and is itching. Which of the following statements by the nurse is the highest priority?
"I'm going to take your heart rate."
"Are you having difficulty breathing?"
"I need to give you diphenhydramine."
"Do you have any allergies to medications?"
The Correct Answer is B
Choice A reason: Taking the heart rate is important, but it is not the highest priority when a client is showing signs of a possible allergic reaction.
Choice B reason: Difficulty breathing may indicate a severe allergic reaction, such as anaphylaxis, which is a medical emergency.
Choice C reason: While administering diphenhydramine is an appropriate action for hives and itching, it is not the highest priority if the client is having difficulty breathing.
Choice D reason: Asking about allergies is important for future reference but does not address the immediate concern of a potential allergic reaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This statement reflects acceptance as the client is taking proactive steps to manage their colostomy independently, which is indicative of adapting to the change in body function.
Choice B reason: While having a partner's support is beneficial, this statement does not necessarily indicate acceptance. It could suggest reliance on others rather than selfcare and acceptance.
Choice C reason: Feeling embarrassed by the colostomy's odor suggests that the client is still struggling with the social implications of their condition, which is not indicative of the acceptance stage.
Choice D reason: Expressing a sense of loss about previous activities, such as attending church meetings, indicates that the client may be in the earlier stages of grieving, such as denial or bargaining, rather than acceptance.
Correct Answer is D
Explanation
Choice A reason: Providing three large meals daily may be overwhelming for a client experiencing changes in taste; smaller, more frequent meals may be better tolerated.
Choice B reason: Heating food before serving can enhance flavor, but it may not be sufficient to address the taste alterations caused by radiation therapy.
Choice C reason: Adding honey to sweeten fruit smoothies can improve taste but may not be suitable for all clients, especially those with diabetes or who need to limit sugar intake.
Choice D reason: Offering artificial saliva can help with dry mouth, a common side effect of radiation therapy, and may improve the client's ability to taste food.
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