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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: When the client has ankle edema is not the most important time for the nurse to assess DTRs, as this is a common finding in pregnancy and does not indicate a neurological or vascular problem. This is a distractor choice.
Choice B: Within the first trimester of pregnancy is not the most important time for the nurse to assess DTRs, as this is a routine assessment that can be done at any time during pregnancy and does not reflect any specific risk or complication. This is another distractor choice.
Choice C: If the client has an elevated blood pressure is the most important time for the nurse to assess DTRs, as this can indicate preeclampsia, a serious condition that can cause seizures, stroke, and organ damage. DTRs can help detect hyperreflexia, which is a sign of increased intracranial pressure and impending eclampsia. Therefore, this is the correct choice.
Choice D: During admission to labor and delivery is not the most important time for the nurse to assess DTRs, as this is a standard assessment that can be done at any stage of labor and does not signify any urgent or emergent situation. This is another distractor choice.
Correct Answer is C
Explanation
Choice A: Yellow-tinged sputum is not a serious adverse effect of linezolid. It may indicate an infection or inflammation in the respiratory tract, but it does not require immediate attention from the health care provider.
Choice B: Nausea and headache are common side effects of linezolid. They are usually mild and self-limiting, and they can be managed with supportive measures such as hydration, rest, and analgesics.
Choice C: Watery diarrhea is a sign of pseudomembranous colitis, a potentially life-threatening complication of linezolid. It is caused by an overgrowth of Clostridium difficile bacteria in the colon, which produce toxins that damage the intestinal mucosa. It can lead to dehydration, electrolyte imbalance, sepsis, and perforation. The nurse should report this finding to the health care provider immediately and stop the linezolid infusion.
Choice D: Increased fatigue is not a specific or serious adverse effect of linezolid. It may be related to the underlying infection, anemia, or other factors. It does not require urgent intervention from the health care provider.
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