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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Supported Sims: The Supported Sims position involves lying on one side with the lower arm behind the back and the upper thigh flexed. This position is not typically recommended for postoperative cholecystectomy patients as it does not provide optimal support for breathing and comfort.
Choice B reason:
Semi-Fowler’s: The Semi-Fowler’s position, where the head of the bed is elevated to about 30-45 degrees, is ideal for postoperative cholecystectomy patients. This position helps facilitate breathing, reduces the risk of aspiration, and promotes comfort by reducing tension on the abdominal muscles.
Choice C reason:
Dorsal recumbent: The Dorsal recumbent position involves lying flat on the back with knees bent and feet flat on the bed. While this position can be used for certain procedures, it is not the most comfortable or beneficial for postoperative cholecystectomy patients as it can increase abdominal pressure and discomfort.
Choice D reason:
Prone: The Prone position, where the patient lies flat on their stomach, is not suitable for postoperative cholecystectomy patients. This position can cause discomfort and does not support optimal breathing or reduce abdominal tension.
Correct Answer is C
Explanation
Choice A reason:
Assist the client to sit upright in a chair for 4 hours at a time: While it is important to mobilize patients after surgery, sitting upright for 4 hours at a time is excessive and can cause discomfort and strain on the surgical site. Early postoperative care focuses on gradual mobilization and avoiding prolonged positions that could stress the spine.
Choice B reason:
Expect clear drainage on the spinal dressing: Clear drainage on the spinal dressing is not typical and could indicate a cerebrospinal fluid (CSF) leak, which is a serious complication. Any unexpected drainage should be reported to the healthcare provider immediately.
Choice C reason:
Log roll the client every 2 hours: Log rolling is a technique used to turn patients while keeping the spine in alignment. This method is crucial for patients who have undergone spinal surgery to prevent twisting or bending of the spine, which could disrupt the surgical site and impede healing. Regular repositioning also helps prevent pressure ulcers.
Choice D reason:
Perform neurological checks every 8 hours: Neurological checks are essential after spinal surgery to monitor for any changes in sensation, movement, or function. However, these checks are typically performed more frequently than every 8 hours, especially in the immediate postoperative period.
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