A nurse administered a dose of penicillin to a client 30 minutes ago. The client reports that she has hives and is itching. Which of the following statements by the nurse is the highest priority?
"I'm going to take your heart rate."
"Are you having difficulty breathing?"
"I need to give you diphenhydramine."
"Do you have any allergies to medications?"
The Correct Answer is B
Choice A reason: Taking the heart rate is important, but it is not the highest priority when a client is showing signs of a possible allergic reaction.
Choice B reason: Difficulty breathing may indicate a severe allergic reaction, such as anaphylaxis, which is a medical emergency.
Choice C reason: While administering diphenhydramine is an appropriate action for hives and itching, it is not the highest priority if the client is having difficulty breathing.
Choice D reason: Asking about allergies is important for future reference but does not address the immediate concern of a potential allergic reaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: A temperature of 37.3°C (99.1°F) is slightly elevated but not necessarily indicative of a bladder infection without other symptoms.
Choice B reason: A WBC count of 9,000/mm is within the normal range (4,500 to 11,000 WBC/mm) and does not specifically suggest a bladder infection.
Choice C reason: Diminished reflexes are not typically associated with bladder infections and may indicate neurological issues.
Choice D reason: In older adults, a change in mental status can be a sign of infection, including a bladder infection, especially when other typical symptoms may not be present.
Correct Answer is D
Explanation
Choice A reason: The MMR vaccine is typically administered during childhood. Adults may need a booster if they have not been vaccinated or if there is an outbreak, but it is not routinely recommended for all older adults.
Choice B reason: The HPV vaccine is recommended for individuals up to age 26, with some guidelines extending to age 45 for those not previously vaccinated. It is not typically recommended for older adults beyond this age range.
Choice C reason: Tuberculosis vaccines are not routinely recommended in the United States for adults unless they are at high risk or have not been previously vaccinated and are traveling to countries where tuberculosis is common.
Choice D reason: The pneumococcal vaccine is recommended for all adults over the age of 65 to protect against pneumococcal diseases such as pneumonia, meningitis, and bloodstream infections.
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