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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Check your oxygen equipment once each week.": Oxygen equipment should be checked daily for proper function and leaks, not just weekly.
B. "Use wool blankets on your bed.": Wool and synthetic fabrics generate static electricity, which can ignite oxygen. Cotton blankets should be used instead.
C. "Store unused oxygen tanks horizontally.": Oxygen tanks should always be stored upright and secured to prevent tipping over.
D. "Do not adjust the oxygen flow rate.": Clients should not change the oxygen flow rate unless instructed by the provider, as improper adjustments can cause oxygen toxicity or hypoxia.
Correct Answer is C
Explanation
A. Allow the client time alone to self-reflect.: Suicidal clients should not be left alone. They require immediate assessment and intervention.
B. Reassure the client that everything is going to work out.: Offering false reassurance can invalidate the client’s feelings and may discourage further discussion of their distress.
C. Ask the client about the lethality of their plan.: The nurse should assess the specifics of the client’s plan to determine the level of risk. A detailed, lethal plan indicates a higher suicide risk and requires immediate intervention.
D. Encourage the client to focus on the positive aspects of life.: While positive reinforcement is helpful, it does not address the immediate risk of suicide. The nurse should prioritize risk assessment and safety.
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