A nurse administered a dose of penicillin to a client 30 min ago.The client reports she has hives and is itching.
Which of the following statements by the nurse is the highest priority?
"Do you have any allergies to medications?"
"Are you having difficulty breathing?"
"I need to give you diphenhydramine.”.
"I'm going to take your heart rate.”.
The Correct Answer is B
Choice A rationale
Asking about allergies is important but is not the highest priority when a client shows signs of a potential allergic reaction.
Choice B rationale
Difficulty breathing is a sign of a severe allergic reaction, requiring immediate intervention to prevent anaphylaxis.
Choice C rationale
Administering diphenhydramine can help with allergic reactions, but assessing for airway issues is the highest priority.
Choice D rationale
Taking the heart rate is essential but not the most immediate concern compared to airway assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Aprepitant is an antiemetic used to prevent nausea and vomiting, particularly in chemotherapy patients. Absence of dizziness is not a primary therapeutic effect of this medication.
Choice B rationale
Decreased incisional pain is not related to the function of aprepitant. Pain management involves different classes of medications, such as analgesics or opioids.
Choice C rationale
Decreased dysrhythmias are not associated with aprepitant's mechanism of action. Cardiac rhythm management requires specific medications targeting heart rhythm disorders.
Choice D rationale
Absence of nausea is a primary therapeutic effect of aprepitant, which works by blocking neurokinin-1 receptors involved in inducing nausea and vomiting. It is effective in managing nausea in patients undergoing chemotherapy. .
Correct Answer is A
Explanation
Choice A rationale
Placing the client in a private room with a private bathroom helps prevent the spread of the infection to other patients and ensures that the client’s wound drainage, which is likely contagious, does not contaminate shared facilities. This isolation measure is crucial in managing infectious wounds.
Choice B rationale
Discarding soiled wound care supplies outside the client's room increases the risk of contaminating common areas. Proper disposal of contaminated materials within the room is necessary to contain the infection.
Choice C rationale
Instructing visitors to perform hand hygiene for only 5 seconds is insufficient. Proper hand hygiene requires at least 20 seconds of scrubbing with soap and water or an alcohol-based hand sanitizer to effectively remove pathogens.
Choice D rationale
Administering antibiotic therapy before culturing the client's wound could interfere with the accuracy of the culture results. Cultures should be obtained before starting antibiotic therapy to identify the causative organism accurately.
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