A nurse is caring for a client who has an allergy to penicillin. The health care provider has prescribed amoxicillin. Which of the following actions should the nurse take?

Discuss the prescription with the health care provider.

Administer the medication as prescribed.

Place an incident report in the medical record.

Call the pharmacist for clarification of the medication contraindications.

Answer and Explanation

The Correct Answer is A

Choice A reason: Discussing the prescription with the provider is critical, as amoxicillin, a penicillin derivative, is contraindicated in clients with penicillin allergies due to risk of anaphylaxis. This ensures patient safety by verifying or correcting the order, aligning with nursing advocacy and safety protocols, making it correct.
Choice B reason: Administering amoxicillin to a client with a penicillin allergy risks severe allergic reactions, including anaphylaxis, violating patient safety principles. Nurses must verify contraindicated orders before administration, making this action dangerous and incorrect in this scenario.
Choice C reason: Placing an incident report is premature, as no error has occurred yet. The nurse’s role is to prevent harm by addressing the contraindicated prescription proactively. This action does not resolve the issue and is inappropriate as the first step, making it incorrect.
Choice D reason: Calling the pharmacist for clarification is less direct than discussing with the provider, who issued the order. While pharmacists can provide guidance, the provider must confirm or change the prescription to ensure safety, making this action secondary and less effective.

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Correct Answer is A

Explanation

Choice A reason: Multiple facial lacerations, if not affecting airway or causing severe bleeding, are minor injuries in triage (green tag). These clients can wait for treatment without immediate risk, aligning with disaster triage principles, making this the correct classification.
Choice B reason: A puncture wound to the lung is life-threatening, potentially causing pneumothorax or hemothorax, requiring urgent intervention (red tag). This is not a minor injury, so it does not qualify for a green tag, making it incorrect.
Choice C reason: Full-thickness burns over the lower extremities are severe, requiring immediate fluid resuscitation and specialized care (red or yellow tag). These are not minor injuries, so this client does not fit green tag criteria, making it incorrect.
Choice D reason: An open compound fracture of the humerus is a significant injury with risks of infection and bleeding, requiring prompt surgical intervention (yellow or red tag). It is not minor, so it does not qualify for a green tag, making it incorrect.

A. Reassure the client that she can have additional children. B. Discourage the client from allowing friends to see the newborn. C. Offer to take pictures of the newborn for the client. D. Advise the client to avoid discussing the stillbirth with family.

Correct Answer is C

Explanation

Choice A reason: Reassuring the client about future children minimizes her current grief and loss, which is inappropriate during initial grieving. This dismisses the emotional significance of the stillbirth, potentially causing distress, making it an insensitive and incorrect action.
Choice B reason: Discouraging friends from seeing the newborn restricts the client’s support system and grieving process. Allowing such interactions can provide closure and comfort, so this action is counterproductive and insensitive, making it incorrect for supporting grief.
Choice C reason: Offering to take pictures of the newborn provides a tangible memory, supporting the client’s grieving process. This sensitive intervention validates the loss and aids emotional healing, aligning with best practices for stillbirth care, making it the correct action.
Choice D reason: Advising against discussing the stillbirth isolates the client and hinders grief processing. Open communication with family fosters support and healing, so this action is harmful and contradicts grief support principles, making it incorrect.

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A nurse is caring for a client who has an allergy to penicillin. The health care provider has prescribed amoxicillin. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse has been assigned to an internal disaster drill team and is triaging clients. Which of the following clients should the nurse classify with a green tag?

Correct Answer is A

Explanation

A nurse is caring for a client who has experienced a stillbirth. Which of the following actions should the nurse take during the initial grieving process?

Correct Answer is C

Explanation

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