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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
"What day of the week and month of the year is it?"
Rationale: Orientation is the awareness of one's personal identity, location, and time. Asking the client what day of the week and month of the year it is can help to assess the client's orientation to time.
Incorrect options:
A) "What is your name and date of birth?" - This question can help to assess the client's orientation to person, but not to location or time.
B) "Do you know where you are and why you are here?" - This question can help to assess the client's orientation to place, but not to person or time.
D) "Do you have any thoughts of harming yourself or others?" - This question can help to assess the client's suicidal or homicidal ideation, but not their orientation.
Correct Answer is C
Explanation
Blood pressure of 90/60 mmHg
Rationale: A blood pressure of 90/60 mmHg indicates hypotension, which is a sign of septic shock and requires immediate intervention. Hypotension results from vasodilation and fluid loss due to the systemic inflammatory response to infection.
Incorrect options:
A) Temperature of 38.5°C (101.3°F) - This is a sign of fever, which is a common symptom of sepsis, but not as urgent as hypotension.
B) Heart rate of 110 beats per minute - This is a sign of tachycardia, which is a compensatory mechanism to maintain cardiac output in sepsis, but not as urgent as hypotension.
D) Respiratory rate of 22 breaths per minute - This is within the normal range for adults and does not indicate respiratory distress.
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