Which is the priority action by the nurse when a patient discloses a medication allergy during the health history before a surgical procedure?
Verifying the information with the patient's family members at the bedside
Placing an alert bracelet on the patient before leaving the unit
Asking the patient to describe the reaction that occurs
Documenting the information on the patient's medical record
The Correct Answer is C
A. Verifying the information with the patient's family members at the bedside: While family members can provide insight, the most critical step is gathering information directly from the patient about the reaction.
B. Placing an alert bracelet on the patient before leaving the unit: While this is necessary, the nurse should first confirm the details of the allergy.
C. Asking the patient to describe the reaction that occurs: The nurse must determine whether the reaction is a true allergy (e.g., anaphylaxis, rash, difficulty breathing) or an intolerance (e.g., nausea, drowsiness). This ensures appropriate precautions are taken.
D. Documenting the information on the patient's medical record: Documentation is crucial but should follow verification of the allergy details.
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Related Questions
Correct Answer is D
Explanation
A. Assessment, diagnosis, intervention, evaluation, discharge, documentation. Discharge and documentation are important but are not part of the core nursing process.
B. Assessment, planning, intervention, evaluation, discharge, follow-up. Follow-up is not a standard step in the nursing process.
C. Assessment, diagnosis, planning, interventions, evaluation, education. Education is important but is not one of the six standard nursing process steps.
D. (Re)Assessment, diagnosis, outcomes, planning, implementation, evaluation. This accurately outlines the nursing process, which involves reassessing the patient, diagnosing, setting expected outcomes, planning care, implementing interventions, and evaluating effectiveness.
Correct Answer is C
Explanation
A. Financial stability: Financial stability is a protective factor against suicide.
B. Engaging in extracurricular activities: Social involvement and participation in activities generally reduce suicide risk.
C. Loss of a job: Job loss is a significant psychosocial stressor that can contribute to feelings of hopelessness, depression, and suicidal ideation.
D. Exercising caution in behavior: Individuals at risk for suicide often engage in impulsive or risky behavior, not cautious behavior.
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