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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Keeping the client's bed in the low position is a safety measure to reduce the risk of injury from falls.
Choice B reason: Positioning the bedside table close to the client is helpful for ensuring that personal items are within reach and does not increase the risk of falls.
Choice C reason: Attaching the call light to the side rail of the client's bed ensures that the client can easily call for assistance and does not increase the risk of falls.
Choice D reason: Instructing the client to wear their own socks to the bathroom can be a risk factor for falls if the socks do not have nonslip grips, as they may cause the client to slip on the floor.
Correct Answer is ["A","B","C"]
Explanation
Choice A reason: Applying SPF 30 sunblock is crucial for clients with SLE to protect their skin from UV light, which can exacerbate the condition.
Choice B reason: Applying lotion twice daily can help maintain skin hydration and integrity, which is important for clients with SLE who may have dry or sensitive skin.
Choice C reason: Gently patting the skin dry after bathing can minimize irritation and is a gentle way to care for sensitive skin, which is beneficial for clients with SLE.
Choice D reason: Limiting time on tanning beds is not advisable; clients with SLE should avoid tanning beds altogether due to the risk of UV light triggering a flareup.
Choice E reason: Using an astringent on reddened areas is not recommended as it can be harsh and drying, which could worsen skin irritation for clients with SLE.
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