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 C
Explanation
Choice A reason: Increasing the IV flow rate may be necessary if the blood pressure is significantly lower than the preoperative value and there are signs of hypovolemia.
Choice B reason: Reassuring the client is important, but it should not be the first action before assessing the clinical significance of the blood pressure reading.
Choice C reason: Comparing the current blood pressure with the preoperative value helps determine the next steps in management and whether the change is within expected limits.
Choice D reason: Covering the client with a warm blanket may be appropriate if the client is feeling cold, but it is not the first action to take in response to the blood pressure reading.
Correct Answer is A
Explanation
Choice A: The fifth intercostal space at the midclavicular line
The point of maximal impulse (PMI), also known as the apical impulse, is usually located in the fifth intercostal space at the midclavicular line. This is the point on the precordium farthest outwards (laterally) and downwards (inferiorly) from the sternum at which the cardiac impulse can be felt.
Choice B: The first intercostal space at the sternal border
The first intercostal space at the sternal border is not typically the location of the PMI. The PMI is usually located in the fifth intercostal space at the midclavicular line.
Choice C: The second intercostal space at the sternal border
The second intercostal space at the sternal border is not typically the location of the PMI. The PMI is usually located in the fifth intercostal space at the midclavicular line.
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