During the admission assessment to the hospital, a male client reports that he is allergic to latex, penicillin, and bananas. Which intervention should the nurse implement first?

Send a list of medication allergies to the pharmacy.

Secure an allergy bracelet around the client's wrist.

Notify the dietary department of the client's fruit allergy.

Place a latex-free supply cart outside the client's room.

Answer and Explanation

The Correct Answer is B

A. Sending a list of medication allergies to the pharmacy is important for preventing adverse drug reactions but is not the immediate priority upon admission.
B. Securing an allergy bracelet around the client's wrist is the first action to ensure that all healthcare providers are immediately aware of the client's allergies, which is crucial for preventing accidental exposure to allergens.
C. Notifying the dietary department is important to prevent allergic reactions from food, but addressing the most immediate concern ensuring the client’s allergies are known to all involved in their care is a higher priority.
D. Placing a latex-free supply cart outside the room is important for preventing latex exposure but is secondary to ensuring that the client’s allergies are clearly communicated through an allergy bracelet.

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Correct Answer is C

Explanation

A. Determining if the expected outcomes were realistic is important but comes after comparing the actual client data with the expected outcomes. If the outcomes were unrealistic, it would be identified during this comparison.
B. Reviewing professional standards of care is important for ensuring that care meets quality standards but is not the immediate next step after reviewing the expected outcomes.
C. Obtaining current client data to compare with expected outcomes is the next step to assess whether the client’s condition has improved, worsened, or remained the same. This comparison is crucial for evaluating the effectiveness of the nursing care.
D. Modifying nursing interventions should be done based on the evaluation of client data and outcomes. It is a subsequent step after assessing whether the outcomes have been met.

A. Tennis shoes with velcro. B. Rubber-soled slippers. C. Slip-on rubber shower shoes. D. Leather-soled loafers.

Correct Answer is A

Explanation

A. Tennis shoes with velcro are recommended because they provide good support, traction, and stability, which are crucial for a client with residual weakness after a stroke. The velcro allows for easy adjustment and ensures the shoes are secure, reducing the risk of tripping or falling.
B. Rubber-soled slippers, while comfortable, may not offer the necessary support or secure fit needed for safe ambulation.
C. Slip-on rubber shower shoes are not suitable for ambulation outside of the shower area due to their lack of support and potential to slip off.
D. Leather-soled loafers can be slippery and do not provide the traction needed for safe walking, especially on smooth surfaces.

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During the admission assessment to the hospital, a male client reports that he is allergic to latex, penicillin, and bananas. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?

Correct Answer is C

Explanation

The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?

Correct Answer is A

Explanation

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