A nurse administered a dose of penicillin to a client 30 min ago. The client reports dizziness and wheezes when breathing. Which of the following questions by the nurse is the highest priority?
"Are you having difficulty breathing?"
"I'm going to take your heart rate."
"I need to give you diphenhydramine."
"Do you have any allergies to medications?"
The Correct Answer is A
Choice A reason: Asking the client if they are having difficulty breathing is the highest priority question, as it can assess the severity of their allergic reaction to penicillin and the risk of anaphylaxis, which is a life-threatening condition that can cause airway obstruction and respiratory failure.
Choice B reason: Taking the client's heart rate is not a question, but an action that can be done after asking the client about their breathing status. The heart rate can indicate the presence of tachycardia or arrhythmia, which are signs of cardiovascular compromise due to an allergic reaction.
Choice C reason: Telling the client that they need to receive diphenhydramine is not a question, but an action that can be done after asking the client about their breathing status. Diphenhydramine is an antihistamine drug that can reduce the symptoms of an allergic reaction, such as itching, swelling, or wheezing.
Choice D reason: Asking the client if they have any allergies to medications is not a high priority question, as it can be done before administering penicillin or after stabilizing the client's condition. Knowing the client's allergy history can help prevent future adverse reactions and guide appropriate treatment choices.Question 42
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Doing testicular self-exam every 6 months without fail is not an adequate frequency, as it can delay the detection of any changes or abnormalities in the testes that may indicate cancer or other conditions. Men should perform testicular self-exam monthly, preferably after a warm bath or shower.
Choice B reason: The flu shot received last year will not last for 2 years, as it only provides protection against specific strains of influenza virus that may change from year to year. People should get a flu shot annually, preferably before the flu season starts.
Choice C reason: Examining breasts a week after each menstrual period is an optimal time, as breasts are less likely to be swollen, tender, or lumpy due to hormonal fluctuations. Women should perform breast self-exam monthly, preferably at the same time each month.
Choice D reason: Getting a hepatitis B vaccine on a yearly basis is not necessary, as it only requires three doses at 0, 1, and 6 months to provide lifelong immunity against hepatitis B virus infection. People who are at high risk of exposure to hepatitis B virus should get tested for antibodies before receiving the vaccine series.
Correct Answer is C
Explanation
The correct answer is C. Consume a diet high in antioxidants.
Choice A: Complete breast self-examinations one week prior to menstruation.
Performing breast self-examinations one week prior to menstruation is not recommended. The best time to perform a breast self-exam is about 3 to 5 days after your period starts, when your breasts are least likely to be tender or swollen. This timing helps in detecting any unusual changes more accurately.
Choice B: Expect clear discharge from the nipples.
While some nipple discharge can be normal, it is not something that should be expected as a routine part of breast health. Clear, yellow, or white discharge can occur due to hormonal changes, but any spontaneous discharge, especially if it is bloody or from one breast, should be evaluated by a healthcare provider.
Choice C: Consume a diet high in antioxidants.
Consuming a diet high in antioxidants is beneficial for overall health and may help reduce the risk of various diseases, including cancer. Antioxidants help neutralize free radicals, which can damage cells and contribute to cancer development. Foods rich in antioxidants include fruits, vegetables, nuts, and whole grains.
Choice D: Include meats grilled over high heat in the diet.
Including meats grilled over high heat in the diet is not advisable for someone concerned about cancer risk. Grilling meats at high temperatures can produce carcinogens such as heterocyclic amines (HCAs) and polycyclic aromatic hydrocarbons (PAHs), which have been linked to an increased risk of cancer. Therefore, it is better to avoid or limit the consumption of grilled meats.
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