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 B
Explanation
Choice A rationale
Using a straw can increase the risk of aspiration in clients with dysphagia as it forces liquid directly to the back of the throat without adequate control.
Choice B rationale
Providing oral care before meals can help stimulate the appetite and ensure that the mouth is clean, reducing the risk of infection and improving the overall eating experience.
Choice C rationale
Scheduling physical therapy directly before meals can cause fatigue, making it more difficult for the client to eat safely and effectively.
Choice D rationale
Tilting the head back can increase the risk of aspiration. The safer method for clients with dysphagia is usually to keep the head in a neutral or slightly forward position when swallowing.
Correct Answer is C
Explanation
Choice A rationale
Discussing changes in family roles is important but is not the immediate priority upon admission. This can be addressed once the client's immediate needs are met.
Choice B rationale
Encouraging verbalization of feelings is crucial for mental health support but is not the most urgent action during admission.
Choice C rationale
Determining the client's ability to see the buttons on the call light ensures their immediate safety and ability to call for help, making it the priority.
Choice D rationale
Assisting with locating a community support group is essential for long-term support but is not the first priority upon admission. .
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