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 C

Explanation

The correct answer is choice C. “This must be a very difficult time for you.”

Choice A rationale:

Asking the mother why she thinks it is her fault can make her feel defensive and does not provide the emotional support she needs at this moment. It may also imply that there could be a reason for her to feel guilty, which is not helpful.

Choice B rationale:

While it is important to provide hope and information about the prognosis, this response does not address the mother’s immediate emotional distress and feelings of guilt. It focuses on the future rather than acknowledging her current emotional state.

Choice C rationale:

This response is empathetic and acknowledges the mother’s feelings. It provides emotional support and validates her experience, which is crucial in helping her cope with the situation.

Choice D rationale:

Telling the mother she did nothing wrong is important, but it does not fully address her emotional distress. It is a factual statement that may not provide the comfort and understanding she needs at this moment.

A. Offer comfort that healing can happen at any point in time. B. Offer strategies the spouse can use to provide comfort to the client. C. Suggest that the spouse go home for a while and get some sleep. D. Explain that the staff will strive to keep the client comfortable.

Correct Answer is D

Explanation

Choice A reason: Offering comfort that healing can happen at any point in time may not be appropriate for a client in the terminal stage of lung cancer, as it may give false hope.

Choice B reason: Offering strategies to provide comfort to the client can be helpful, but it does not address the spouse's immediate emotional needs.

Choice C reason: Suggesting that the spouse go home to sleep may seem dismissive of the spouse's current emotional state and need for support.

Choice D reason: Explaining that the staff will strive to keep the client comfortable addresses the spouse's concern for the client's well-being and provides reassurance about the care being provided.

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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 mother of a child born with Tetralogy of Fallot asks the nurse, "Why did this happen to my baby? What did I do wrong?" Which response by the nurse is most helpful?

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Correct Answer is D

Explanation

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