A nurse is admitting a client who has a partial hearing loss.
Which of the following is the priority action by the nurse?

Rephrase statements the client does not hear.

Determine if the client uses hearing aids.

Speak using his usual tone of voice and directly in front of the client.

Use hand gestures to communicate.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Rephrasing statements the client does not hear is helpful but not the priority action. The priority is to determine if the client uses hearing aids to ensure they can hear instructions and communication effectively.

Choice B rationale

Determining if the client uses hearing aids is the priority action. Ensuring the client has and uses their hearing aids can significantly improve communication and care.

Choice C rationale

Speaking using the usual tone of voice and directly in front of the client is important but secondary to ensuring the client has their hearing aids.

Choice D rationale

Using hand gestures to communicate can be helpful but is not the priority action. The primary focus should be on ensuring the client has their hearing aids for optimal hearing.

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Correct Answer is C

Explanation

Choice A rationale

Auscultating for wheezing is important but not the first action. The priority is to administer epinephrine to counteract the severe allergic reaction.

Choice B rationale

Assessing the client’s level of consciousness is important but not the first action. Administering epinephrine takes precedence to stabilize the client’s condition.

Choice C rationale

Administering epinephrine is the first action. It is crucial to counteract the severe allergic reaction and prevent further complications.

Choice D rationale

Monitoring for hypotension is important but not the first action. Administering epinephrine is the priority to stabilize the client’s condition.

A. Intubation equipment and oxygen. B. Epinephrine. C. Blood administration equipment. D. Foley catheter.

Correct Answer is ["A","B"]

Explanation

Choice A rationale

Intubation equipment and oxygen are essential for managing airway obstruction and ensuring adequate oxygenation in a patient experiencing anaphylaxis due to a severe peanut allergy.

Choice B rationale

Epinephrine is the first-line treatment for anaphylaxis as it rapidly reverses the symptoms by constricting blood vessels, relaxing muscles in the airways, and reducing swelling.

Choice C rationale

Blood administration equipment is not typically required for managing anaphylaxis unless there is a concurrent condition that necessitates it.

Choice D rationale

A Foley catheter is not relevant to the immediate management of anaphylaxis.

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A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is caring for a client who is suspected to have anaphylaxis following a bee sting. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

While working in the emergency department, the unit secretary says, “We just got a call that someone with a severe peanut allergy accidentally ate peanuts and is on the way.”. Which emergency equipment would the nurse gather to prepare for the client’s arrival? Select all that apply.

Correct Answer is ["A","B"]

Explanation

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A nurse is admitting a client who has a partial hearing loss.
Which of the following is the priority action by the nurse?