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 B
Explanation
Choice A reason: Sterile gloves should be donned after removing the old dressing and before handling the new sterile dressing.
Choice B reason: Offering pain medication before the procedure can help manage discomfort during the dressing change.
Choice C reason: Disinfecting the wound bed with alcohol is not recommended as it can damage new tissue and delay healing.
Choice D reason: Preparing sterile dressing supplies should be done just before the dressing change to maintain sterility.
Correct Answer is D
Explanation
Choice A reason:Aspiration pneumonia is typically caused by inhalation of foreign material into the lungs rather than by contagious pathogens. Therefore, standard precautions are usually sufficient unless a secondary infection with a transmissible organism is present.
Choice B reason: Applying petroleum jelly to the client's nares may provide comfort but is not a priority in the care plan.
Choice C reason: Maintaining the client in a supine position is contraindicated as it can increase the risk of aspiration.
Choice D reason: Clients with hypoxia may experience symptoms such as confusion, restlessness, and dizziness, which can increase the risk of falls. Implementing fall precautions is a proactive measure to ensure patient safety in this context.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today