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:

Place a black tag on the client’s upper body and attempt to help the next client in need: In mass casualty incidents, triage is used to prioritize treatment based on the severity of injuries and the likelihood of survival. A black tag indicates that the victim is deceased or has injuries that are not compatible with life and that resources should be directed to those who have a better chance of survival. Since the client remains apneic even after repositioning the airway, it indicates that they are not breathing and have a very low chance of survival.

Choice B reason:

Reposition the client’s upper airway a second time before assessing his respirations: While ensuring the airway is open is crucial, if the client remains apneic after the initial repositioning, further attempts are unlikely to be successful in a mass casualty scenario where time and resources are limited2. The priority is to move on to other victims who may have a higher chance of survival.

Choice C reason:

Start CPR: In a mass casualty situation, CPR is typically not initiated for victims who are apneic and pulseless due to the need to allocate resources to those who have a higher likelihood of survival3. The focus is on providing immediate care to those who can benefit the most from it.

Choice D reason:

Place a red tag on the client’s upper body and obtain immediate help from other personnel: A red tag is used for victims who require immediate life-saving interventions and have a high chance of survival if treated promptly4. Since the client is apneic and remains so after airway repositioning, they do not meet the criteria for a red tag.

A. Use wool blankets on your bed. B. Do not adjust the oxygen flow rate. C. Store unused oxygen tanks horizontally. D. Check your oxygen equipment once each week.

Correct Answer is B

Explanation

Choice A reason: Use Wool Blankets on Your Bed

Using wool blankets is not recommended for clients on home oxygen therapy. Wool and other materials that can generate static electricity pose a fire hazard when used around oxygen. Instead, clients should use cotton or other non-static generating materials to reduce the risk of fire.

Choice B reason: Do Not Adjust the Oxygen Flow Rate

This statement indicates an understanding of the teaching. Clients should not adjust the oxygen flow rate unless instructed by their healthcare provider. The prescribed flow rate is set to meet the client’s specific needs, and any changes could lead to inadequate oxygenation or other complications.

Choice C reason: Store Unused Oxygen Tanks Horizontally

This statement is incorrect. Oxygen tanks should be stored upright and secured to prevent them from falling over. Storing tanks horizontally can increase the risk of damage and potential leaks, which can be hazardous.

Choice D reason: Check Your Oxygen Equipment Once Each Week

While it is important to regularly check oxygen equipment, doing so only once a week may not be sufficient. Clients should check their equipment daily to ensure it is functioning properly and to identify any issues that need to be addressed promptly.

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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?

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