A nurse is assisting in the care of a client who is receiving newly prescribed IV antibiotics. Which of the following findings should the nurse report immediately?
Small, raised vesicles over the body
Rhinitis
Itching of the skin
Severe wheezing
The Correct Answer is D
Rationale:
A. Small, raised vesicles over the body may indicate an allergic reaction but are not typically associated with IV antibiotics.
B. Rhinitis may indicate an allergic reaction but is not typically associated with IV antibiotics.
C. Itching of the skin may indicate an allergic reaction but is not typically associated with IV antibiotics.
D. Severe wheezing may indicate an allergic reaction or anaphylaxis and should be reported immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Telling the nurse that permission from the risk manager is required to view the client's record is not accurate and may not address the situation appropriately.
B. Contacting facility security to remove the nurse from the unit is not necessary and may not address the situation appropriately.
C. Completing an incident report about the breach of confidentiality may be appropriate later if the situation escalates or if there is no resolution after speaking to the nurse. However, the immediate step is to address the breach directly.
D. Reminding the nurse that only staff caring for the client may access the client's record is the correct action. The nurse should remind the colleague that access to a client's medical record is restricted to those directly involved in their care. This respects patient confidentiality and complies with legal and ethical guidelines.
Correct Answer is C
Explanation
Rationale:
A. Administering diuretics in the evening may increase the client's need to urinate and disrupt sleep.
B. Using overhead lighting when checking equipment may disrupt the client's sleep and should be avoided.
C. Keeping the door to the client's room closed can reduce noise and disturbances from the hallway, promoting a more restful sleep environment.
D. Providing snug-fitting nightwear may be uncomfortable and restrict movement during sleep.
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