A nurse is preparing to administer an intramuscular injection to a client who has a latex allergy.

Which action should the nurse take to prevent an allergic reaction?

Use a filter needle to draw up the medication from the vial

Use a non-latex glove to palpate the injection site

Use an alcohol swab to cleanse the injection site

Use a Z-track technique to inject the medication

Answer and Explanation

The Correct Answer is B

Use a non-latex glove to palpate the injection site

Rationale: The nurse should use a non-latex glove to palpate the injection site, as latex gloves can cause skin irritation, rash, or anaphylaxis in clients who have a latex allergy.

Incorrect options:

A) Use a filter needle to draw up the medication from the vial - This action is not related to preventing an allergic reaction, but rather to preventing contamination or injury from glass particles that may be present in some vials.

C) Use an alcohol swab to cleanse the injection site - This action is not related to preventing an allergic reaction, but rather to preventing infection by reducing the number of microorganisms on the skin.

D) Use a Z-track technique to inject the medication - This action is not related to preventing an allergic reaction, but rather to preventing leakage or irritation of the medication into the subcutaneous tissue by creating a zigzag path with the needle.

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Correct Answer is C

Explanation

A black nodule with an irregular border and asymmetrical shape

Rationale: A black nodule with an irregular border and asymmetrical shape is consistent with the ABCDE criteria for melanoma, which are: Asymmetry, Border irregularity, Color variation, Diameter greater than 6 mm, and Evolving or changing appearance.

Incorrect options:

A) A brown mole with a smooth border and symmetrical shape - This is a normal finding that does not indicate malignancy.

B) A red macule with a flat surface and well-defined edges - This is likely a benign vascular lesion, such as a cherry angioma or petechiae.

D) A yellow papule with a raised surface and round edges - This is likely a benign sebaceous lesion, such as a sebaceous cyst or milia.

A. "The client reports feeling short of breath and fatigued." B. "The client has crackles in the lower lobes bilaterally." C. "The client states that he has been coughing up green sputum." D. "The client rates his pain as 4 out of 10 on a numeric scale."

Correct Answer is B

Explanation

"The client has crackles in the lower lobes bilaterally."

Rationale: Objective data are observable and measurable facts that can be verified by the nurse or another health care provider. Crackles are an abnormal lung sound that can be heard with a stethoscope and indicate fluid accumulation in the alveoli.

Incorrect options:

A) "The client reports feeling short of breath and fatigued." - This is an example of subjective data, which are information that only the client can perceive and describe, such as feelings, sensations, and beliefs.

C) "The client states that he has been coughing up green sputum." - This is also an example of subjective data, as it is based on the client's verbal report.

D) "The client rates his pain as 4 out of 10 on a numeric scale." - This is another example of subjective data, as pain is a personal experience that cannot be directly measured by the nurse.

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A nurse is preparing to administer an intramuscular injection to a client who has a latex allergy. Which action should the nurse take to prevent an allergic reaction?

Nursing Test Bank

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A nurse is preparing to administer an intramuscular injection to a client who has a latex allergy. Which action should the nurse take to prevent an allergic reaction?

A nurse is preparing to administer an intramuscular injection to a client who has a latex allergy.

Which action should the nurse take to prevent an allergic reaction?