Thirty minutes after receiving meperidine, the client develops a temperature of 101°F and the skin is warm and flushed with a notable rash on the chest and back.
The nurse contacts the primary health care provider and begins to document on an incident report.
Which information should be included?
The client had an allergic reaction to the ordered meperidine.
The primary health care provider was notified because the client developed a rash after receiving an opioid analgesic.
The client’s skin was warm and flushed, and a rash was noted on the chest and back.
Thirty minutes after receiving meperidine, the temperature was 101°F (38.3°C).
The Correct Answer is D
Choice A rationale
Stating that the client had an allergic reaction to the ordered meperidine is not objective and does not provide specific details about the client’s condition.
Choice B rationale
Notifying the primary health care provider because the client developed a rash after receiving an opioid analgesic is important, but it does not include all the necessary details about the client’s condition.
Choice C rationale
Documenting that the client’s skin was warm and flushed, and a rash was noted on the chest and back is important, but it does not include the timing of the reaction or the client’s temperature.
Choice D rationale
Documenting that thirty minutes after receiving meperidine, the temperature was 101°F (38.3°C), the client’s skin was warm and flushed, and a rash was noted on the chest and back provides a complete and objective account of the client’s condition and the timing of the reaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Applying cool compresses can help reduce swelling and discomfort, but it is not the primary instruction for a client scheduled for retinal detachment surgery.
Choice B rationale
Eye drops to constrict the pupils are not typically prescribed for retinal detachment surgery. The focus is on preventing further detachment and ensuring proper healing.
Choice C rationale
Restricting head movement is crucial to prevent further detachment of the retina and to promote proper healing after surgery. The client should be instructed to avoid sudden or excessive head movements.
Choice D rationale
Keeping both eyes patched is not necessary and may cause unnecessary discomfort and disorientation for the client.
Correct Answer is ["B","D","F"]
Explanation
Choice A rationale
Avoiding the use of insect repellent on the skin and clothing is not recommended. Insect repellents containing DEET are effective in preventing tick bites, which can transmit Lyme disease. The toxicity of DEET is minimal when used as directed.
Choice B rationale
Avoiding heavily wooded areas and areas with thick underbrush is recommended to reduce the risk of tick exposure. Ticks that carry Lyme disease are commonly found in these environments.
Choice C rationale
Wearing dark clothing is not recommended as it makes it harder to spot ticks. Light-colored clothing is preferable as it allows for easier detection of ticks.
Choice D rationale
Wearing long-sleeved tops and long pants with closed shoes is recommended to minimize skin exposure and reduce the risk of tick bites.
Choice E rationale
Reporting to the primary health care provider immediately for a blood test if a tick is found is not necessary. The presence of a tick does not immediately indicate Lyme disease. Instead, the tick should be removed promptly, and the area should be monitored for signs of infection.
Choice F rationale
Bathing after being in an infested area and inspecting the body carefully for ticks is recommended. This helps in early detection and removal of ticks, reducing the risk of Lyme disease.
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