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 D
Explanation
Choice A reason: Ammonia 55 mg/dL is within the normal range of 15 to 60 mg/dL and does not indicate any liver dysfunction or bleeding risk.
Choice B reason: Bilirubin 1.0 mg/dL is within the normal range of 0.3 to 1.2 mg/dL and does not indicate any liver damage or jaundice.
Choice C reason: Aspartate aminotransferase 34 units/L is within the normal range of 10 to 40 units/L and does not indicate any liver inflammation or injury.
Choice D reason: Platelets 60,000/mm³ is below the normal range of 150,000 to 450,000/mm³ and indicates thrombocytopenia, which is a low platelet count that can increase the risk of bleeding during or after the liver biopsy. The nurse should report this value to the provider and monitor the client for signs of bleeding, such as bruising, petechiae, hematuria, or melena.
Correct Answer is A
Explanation
Choice A reason: Taking ibuprofen or other nonsteroidal anti-inflammatory drugs (NSAIDs) can cause a false-positive result on a fecal occult blood screening test, as they can irritate the gastrointestinal mucosa and cause bleeding.
Choice B reason: Having a hemorrhoidectomy 1 year ago is unlikely to cause a false-positive result on a fecal occult blood screening test, as hemorrhoids are usually a source of bright red blood that can be seen with naked eye, not occult blood that requires chemical detection.
Choice C reason: Having a history of breast cancer is not related to a false-positive result on a fecal occult blood screening test, as breast cancer does not affect the gastrointestinal tract or cause bleeding in stool.
Choice D reason: Consuming citrus juice 3 days before the test is not likely to cause a false-positive result on a fecal occult blood screening test, as citrus juice does not contain any substances that can interfere with the chemical reaction of the test. However, consuming red meat, raw vegetables, vitamin C supplements, or iron supplements within 3 days before the test can cause false-negative results, as they can mask or degrade occult blood in stool.
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