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.”.

Answer and Explanation

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.

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Correct Answer is D,B,E,A,C

Explanation

Choice Drationale

Cleansing the site with an antiseptic swab reduces the risk of infection by removing surface bacteria and contaminants. It is essential to prepare the site adequately for a clean puncture.

Choice B rationale

Allowing the site to dry prevents the antiseptic from diluting the blood sample and ensures accurate readings. Moisture at the puncture site can interfere with the effectiveness of the glucose meter.

Choice Erationale

Piercing the puncture site quickly minimizes discomfort for the client and ensures a clean puncture. A swift puncture reduces the risk of the site becoming overly irritated or bruised.

Choice Arationale

Squeezing the site gently helps to obtain an adequate blood sample without causing excessive damage to the surrounding tissue. It ensures a sufficient droplet size for testing without causing additional trauma.

Choice Crationale

Applying blood to the test strip allows the glucose meter to measure the blood glucose level accurately. It is the final step in obtaining a capillary blood sample for testing. .

A. Monitor for at least 150 mL of drainage every hour. B. Replace the unit when the drainage chamber is full. C. Clamp the tube for 30 min every 8 hr. D. Pin the tubing to the client's bed sheets.

Correct Answer is B

Explanation

Choice A rationale

Monitoring for at least 150 mL of drainage every hour is excessive; the expected drainage is around 70-100 mL per hour. This amount indicates a potential complication.

Choice B rationale

Replacing the unit when the drainage chamber is full is correct to maintain the efficiency of the closed-chest tube drainage system and prevent overflow.

Choice C rationale

Clamping the tube for 30 minutes every 8 hours can cause tension pneumothorax and is not recommended.

Choice D rationale

Pinning the tubing to the client's bed sheets can cause kinks and obstruction, which can lead to complications.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D,B,E,A,C

Explanation

A nurse is assisting with the care of a client who has a closed-chest tube drainage system.Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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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?