A nurse working on a medical unit is completing the admission of a client who reports a severe allergy to penicillin. Which of the following actions should the nurse take?

Remove all objects that contain latex from the client’s room.

Verify the client’s medication prescriptions do not include cephalosporin.

Notify dietary services to adjust the client’s diet.

Have the client purchase a medication alert bracelet to wear in the hospital.

Answer and Explanation

The Correct Answer is B

Choice A reason:

Removing all objects that contain latex from the client’s room is important for clients with a latex allergy, not a penicillin allergy. Latex allergies can cause severe reactions, including anaphylaxis, but this action is not relevant to a penicillin allergy.

Choice B reason:

Verifying that the client’s medication prescriptions do not include cephalosporin is crucial because cephalosporins can have cross-reactivity with penicillin. Clients with a penicillin allergy may also react to cephalosporins, so it is essential to avoid prescribing these antibiotics.

Choice C reason:

Notifying dietary services to adjust the client’s diet is not directly related to managing a penicillin allergy. Dietary adjustments are more relevant for clients with food allergies or specific dietary restrictions.

Choice D reason:

Having the client purchase a medication alert bracelet to wear in the hospital is a good practice for general safety, but it is not an immediate action the nurse should take during the admission process. The primary focus should be on ensuring that the client’s medications do not include penicillin or related antibiotics.

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Correct Answer is A

Explanation

Choice A reason:

The first step in removing an NG tube is to verify the provider’s prescription to discontinue the tube. This ensures that the removal is authorized and appropriate for the client’s current condition.

Choice B reason:

Disconnecting the tube from the wall suction is an important step, but it should be done after verifying the provider’s prescription. This step prevents any suction-related complications during the removal process.

Choice C reason:

Performing hand hygiene is crucial to prevent infection, but it is not the first step. Hand hygiene should be performed after verifying the provider’s prescription and before touching the client or any equipment.

Choice D reason:

Providing mouth care to the client is important for comfort and hygiene, but it is not the first step in the process of removing an NG tube. This can be done after the tube has been safely removed.

A. Your largest meal of the day should be in the evening. B. Eating yogurt can help decrease the amount of gas that I have. C. Carbonated beverages can help control odor. D. I should eliminate pasta from my diet so that I don’t have many loose stools.

Correct Answer is B

Explanation

Choice A reason:

Advising that the largest meal of the day should be in the evening is not typically recommended for clients with a colostomy. It is generally better to have smaller, more frequent meals throughout the day to aid digestion and reduce the risk of discomfort.

Choice B reason:

Eating yogurt can indeed help decrease the amount of gas. Yogurt contains probiotics, which can aid in digestion and reduce gas production. This is a beneficial dietary choice for clients with a colostomy.

Choice C reason:

Carbonated beverages are not recommended for controlling odor. In fact, they can increase gas production and lead to bloating, which can be uncomfortable for clients with a colostomy.

Choice D reason:

There is no need to eliminate pasta from the diet to prevent loose stools. Instead, clients should focus on a balanced diet that includes low-fiber foods initially and gradually reintroduce other foods while monitoring their effects.

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A nurse working on a medical unit is completing the admission of a client who reports a severe allergy to penicillin. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to remove an NG tube from a client. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is caring for a client following the surgical placement of a colostomy. Which of the following statements indicates the client understands the dietary teaching?

Correct Answer is B

Explanation

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