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. The Trendelenburg position is not appropriate for managing low oxygen saturation levels and may not address the underlying issue. This position is more commonly used for hypotension, not hypoxemia.
B. Documenting the reading is important for record-keeping but does not address the immediate concern of the client's low oxygen saturation levels.
C. Ensuring that the nasal cannula is securely placed in the nostrils is crucial for effective oxygen delivery. A loose or improperly positioned cannula can result in inadequate oxygenation, contributing to lower oxygen saturation readings.
D. While placing the pulse oximeter on the earlobe might provide a different reading, it is essential first to ensure that the current oxygen delivery system is functioning properly and the cannula is properly positioned.

A. Engage the client in relaxation exercises. B. Offer to sit with the client until she relaxes. C. Administer a prescribed PRN analgesic. D. Assist the client to a different position.

Correct Answer is D

Explanation

A. Engaging the client in relaxation exercises may be helpful but should be considered after addressing potential physical causes of discomfort, such as positioning.
B. Offering to sit with the client is supportive, but the primary issue of physical discomfort should be addressed first.
C. Administering a PRN analgesic may be necessary if the discomfort persists, but repositioning the client is a less invasive intervention to try first.
D. Assisting the client to a different position is the first action the nurse should take. A change in position can often alleviate discomfort for bedfast clients and is a simple, non-invasive intervention.

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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?

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Correct Answer is C

Explanation

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Correct Answer is D

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