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: A Client Who Has a Small Circular Partial-Thickness Burn of the Left Calf
A small circular partial-thickness burn of the left calf is considered a minor injury in the context of a mass casualty event. This type of injury does not pose an immediate threat to life and can be managed after more critical cases are addressed. In mass casualty triage, patients with minor injuries are often categorized as “green” or “minimal” and are treated last.
Choice B reason: A Client Who Has Severe Respiratory Stridor and a Deviated Trachea
A client with severe respiratory stridor and a deviated trachea should be assessed first. These symptoms indicate a potential airway obstruction, which is a life-threatening condition requiring immediate intervention. In mass casualty triage, patients with compromised airways are given the highest priority and are categorized as “red” or “immediate” because their condition is critical and requires urgent medical attention.
Choice C reason: A Client Who Has a Splinted Open Fracture of the Left Medial Malleolus
A splinted open fracture of the left medial malleolus is a serious injury but not immediately life-threatening if properly splinted. This client would be categorized as “yellow” or “delayed” in mass casualty triage, meaning they require medical attention but can wait until more critical patients are stabilized.
Choice D reason: A Client Who Has a Massive Head Injury and Is Experiencing Seizures
A client with a massive head injury and experiencing seizures is in a critical condition. However, in the context of mass casualty triage, the immediate priority is to secure the airway, breathing, and circulation. While this client is in dire need of medical attention, the presence of severe respiratory stridor and a deviated trachea in another client takes precedence due to the immediate threat to life.
Correct Answer is ["A","B","D","E"]
Explanation
Choice A reason:
Clean clothing is necessary for maintaining hygiene and comfort in disaster situations. Limited access to laundry facilities makes having extra clothing essential for preventing infections and staying dry in extreme weather.
Choice B reason:
Personal identification is crucial during emergencies to access aid, medical services, and shelters. Important documents such as passports or insurance cards help verify identity and facilitate assistance.
Choice C reason:
Three quarts of water per person is not the recommended amount. The standard guideline advises one gallon of water per person per day to meet hydration and sanitation needs, ensuring sufficient supply in prolonged emergencies.
Choice D reason:
Matches are useful for starting fires needed for cooking, warmth, and signaling for help. Waterproof matches or lighters should be included to ensure functionality in wet conditions.
Choice E reason:
Prescription medications are vital for those with chronic health conditions. Having a sufficient supply ensures continuity of treatment, especially when pharmacies may be inaccessible during disasters.
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