When conducting an admission assessment, the nurse notes that an adult female client has developed two new allergies since her last admission. The client describes herself as lactose intolerant and states that she is unable to eat eggs. Which intervention(s) should the nurse implement? (Select all that apply.)
Apply an allergy identification wrist band.
Instruct the client to avoid medication containing milk and eggs.
Enter allergy information in the client's electronic medical record.
Ensure the client's selections from her dietary menu.
Notify the dietary department of the client's egg intolerance.
Correct Answer : A,C,D,E
Choice A: Applying an allergy identification wrist band is an intervention that the nurse should implement, as this can alert other health care providers of the client's allergies and prevent adverse reactions. Therefore, this is a correct choice.
Choice B: Instructing the client to avoid medication containing milk and eggs is not an intervention that the nurse should implement, as this is not a common or relevant source of allergens for this client. This is an incorrect choice.
Choice C: Entering allergy information in the client's electronic medical record is an intervention that the nurse should implement, as this can ensure accurate and updated documentation of the client's allergies and facilitate communication among health care providers. Therefore, this is another correct choice.
Choice D: Ensuring the client's selections from her dietary menu is an intervention that the nurse should implement, as this can help avoid foods that may trigger allergic reactions or intolerance for this client. Therefore, this is another correct choice.
Choice E: Notifying the dietary department of the client's egg intolerance is an intervention that the nurse should implement, as this can help modify or substitute foods that contain eggs for this client. Therefore, this is another correct choice.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: 18%. This is not the correct percentage, as it only accounts for one lower extremity. According to the rule of nines, each lower extremity accounts for 9% of body surface area on both anterior and posterior sides, so both lower extremities would account for 18% x 2 = 36%.
Choice B: 27%. This is not the correct percentage, as it only accounts for one and a half lower extremities. According to the rule of nines, each lower extremity accounts for 9% of body surface area on both anterior and posterior sides, so one and a half lower extremities would account for 9% x 3 = 27%.
Choice C: 36%. This is the correct percentage, as it accounts for both lower extremities. According to the rule of nines, each lower extremity accounts for 9% of body surface area on both anterior and posterior sides, so both lower extremities would account for 9% x 4 = 36%.
Choice D: 45%. This is not the correct percentage, as it accounts for more than both lower extremities. According to the rule of nines, each lower extremity accounts for 9% of body surface area on both anterior and posterior sides, so more than both lower extremities would account for more than 9% x 4 = 36%.
Correct Answer is A
Explanation
The correct answer is A:
Choice A reason: Review the need for the UAP to wear a face mask while in close contact with the client. Influenza is a respiratory virus that spreads mainly by droplets made when people with flu cough, sneeze or talk.A face mask can help block the spread of these droplets.
Choice B reason:Reminding the UAP to apply a fitted respirator mask before entering the client’s room is not necessary for standard influenza precautions.Respirator masks are more commonly used for airborne precautions, such as tuberculosis or measles, not for influenza.
Choice C reason:Assigning the UAP to provide care for another client and assuming full care of the client is not indicated unless the UAP is not following proper infection control procedures.There is no evidence of that in the scenario provided.
Choice D reason:Instructing the UAP to notify the nurse of any changes in the client’s respiratory status is important, but it is not the immediate action related to infection control.The priority is to prevent the spread of infection.
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