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:
Creatinine: Creatinine is a waste product produced by muscles and is filtered out of the blood by the kidneys. Elevated creatinine levels can indicate kidney dysfunction. However, in this scenario, the primary concern is liver damage due to the combination of alcohol and acetaminophen, making AST a more relevant marker.
Choice B reason:
Aspartate aminotransferase (AST): AST is an enzyme found in the liver and heart. Elevated levels of AST can indicate liver damage. Given the client’s high intake of both alcohol and acetaminophen, there is a significant risk of liver damage. Monitoring AST levels can help assess the extent of liver injury.
Choice C reason:
Amylase: Amylase is an enzyme produced by the pancreas and salivary glands that helps in the digestion of carbohydrates. Elevated amylase levels are typically associated with pancreatic disorders, such as pancreatitis. While important, it is not the priority in this case where liver damage is the main concern.
Choice D reason:
Antidiuretic hormone (ADH): ADH is a hormone that helps regulate water balance in the body by controlling the amount of water reabsorbed by the kidneys. Abnormal levels of ADH can indicate issues with fluid balance, but it is not directly related to liver function or the effects of alcohol and acetaminophen.
Correct Answer is B
Explanation
Choice A reason:
Saying “Maybe next time you can have a vaginal delivery” is not supportive and may minimize the client’s current feelings of disappointment. It is important to acknowledge and validate the client’s emotions rather than focusing on future possibilities.
Choice B reason:
This response, “It sounds like you are feeling sad that things didn’t go as planned,” is empathetic and validates the client’s feelings. It shows that the nurse is listening and understands the client’s disappointment, which is crucial for emotional support.
Choice C reason:
While it is true that having a healthy baby is important, saying “At least you know you have a healthy baby” can come across as dismissive of the client’s feelings. It is essential to address the client’s emotions directly rather than shifting the focus.
Choice D reason:
Telling the client “You can resume sensations sooner than if you had delivered vaginally” is not relevant to the client’s expressed feelings of disappointment about not having a natural childbirth. This response does not address the emotional aspect of the client’s experience.
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