A nurse is caring for a client with an allergic skin condition. The client develops wheezing, a swollen tongue, and hives. Which of the following is the nursing priority?

Assessing the client's neurologic status

Consulting an allergy specialist

Administering epinephrine

Determining the cause of the hives

Answer and Explanation

The Correct Answer is C

Administering epinephrine is the immediate priority when managing anaphylaxis. Epinephrine is the first-line treatment for anaphylaxis as it helps to rapidly reverse severe allergic symptoms, such as airway constriction, swelling, and hypotension.

A. While assessing the client's neurologic status is important for monitoring their overall condition, it may not be the immediate priority when the client is experiencing symptoms of an allergic reaction, particularly anaphylaxis.

B. While consulting an allergy specialist may be necessary for further evaluation and management of the client's allergic condition, it is not the immediate priority.

D. While determining the cause of the hives is important for identifying the allergen and preventing future allergic reactions, it is not the immediate priority during an acute episode of anaphylaxis.

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

Explanation

This information is relevant to the client's condition and should be documented in the medical record. It provides important information about the client's physical status following the fall and may influence subsequent care decisions.

B. This information is typically documented in the incident report itself rather than the client's medical record. While it is important for the healthcare facility's records, it is not typically included in the client's medical record unless there are specific policies or procedures mandating such documentation.

C. This information is more relevant to administrative records and risk management procedures rather than the client's medical record.

D. This information is relevant to the client's care and should be documented in the medical record. It indicates that appropriate actions were taken following the incident.

A. Speak to the client in the third person. B. Make eye contact with the client when speaking C. Have the interpreter sit in front of the client. D. Use long sentences when speaking to the client.

Correct Answer is C

Explanation

A. The nurse should speak directly to the client in the first person, even when using an interpreter. Speaking in the third person can create confusion and distance in communication.

B. This action demonstrates respect and engagement with the client, even though the nurse is using an interpreter. Eye contact can help to build rapport and ensure that the client feels heard and understood.
C. The interpreter should ideally sit beside or slightly behind the nurse, allowing the nurse and client to see each other while the interpreter translates. This setup fosters a more personal interaction between the nurse and the client.
D. Using long sentences can make it difficult for the interpreter to accurately translate the message.

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A nurse is caring for a client with an allergic skin condition. The client develops wheezing, a swollen tongue, and hives. Which of the following is the nursing priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

A nurse is using a medical interpreter to communicate with a client. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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