During the admission assessment to the hospital, an adult client reports being allergic to latex, penicillin, and bananas. Which intervention should the nurse implement first?

Secure an allergy bracelet around the client's wrist.

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

Send a list of medication allergies to the pharmacy.

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

Answer and Explanation

The Correct Answer is A

Choice A reason: An allergy bracelet provides immediate visual notification of the client's allergies to all healthcare personnel, which is crucial for preventing allergic reactions.

Choice B reason: Notifying the dietary department is important, but it does not have the same immediate impact on client safety as an allergy bracelet.

Choice C reason: Sending a list of medication allergies to the pharmacy is a necessary step, but it is secondary to providing immediate identification of the client's allergies.

Choice D reason: Placing a latex-free supply cart outside the room is a proactive measure to prevent exposure to latex, but the first step should be to ensure that the client's allergies are clearly identified for all staff.

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Correct Answer is D

Explanation

Choice A reason: While heart rate is important, it is not the most immediate concern when a client shows signs of cyanosis.

Choice B reason: Blood pressure is a critical vital sign but does not directly address the issue of oxygenation, which is suggested by cyanosis.

Choice C reason: Temperature is less relevant to the immediate assessment of cyanosis, which is often related to oxygenation issues.

Choice D reason: Respiratory rate should be assessed first as cyanosis is a sign of potential hypoxia, and the respiratory rate can provide immediate information about the client's breathing and oxygenation status.

A. Bowel incontinence. B. Impaired bed mobility. C. Fluid volume deficit. D. Caregiver role strain.

Correct Answer is C

Explanation

Choice A reason: While bowel incontinence is a concern, it does not pose an immediate threat to the client's physiological stability like fluid volume deficit does.

Choice B reason: Impaired bed mobility is important to address for long-term rehabilitation, but it is not the most immediate threat to life.

Choice C reason: Fluid volume deficit, especially due to diarrhea, can lead to dehydration and is a life-threatening condition that requires immediate intervention.

Choice D reason: Caregiver role strain is a significant issue but does not take precedence over the client's immediate physical health needs.

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During the admission assessment to the hospital, an adult client reports being allergic to latex, penicillin, and bananas. Which intervention should the nurse implement first?

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Naxlex Comprehensive Predictor Exams

The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first?

Correct Answer is D

Explanation

The nurse identifies several nursing problems for a client who is incontinent and immobile after a stroke and is now experiencing diarrhea. The client resides at home, and the spouse is the primary caregiver. While planning care, the nurse should determine which problem has the highest priority?

Correct Answer is C

Explanation

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