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?"

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A. Respiratory rate
Reason: After thoracentesis, it's crucial to monitor the patient's respiratory rate. An increased respiratory rate could indicate respiratory distress. In this case, the respiratory rate is 26/min, which is higher than the normal range (12-20 breaths per minute for an adult at rest). Therefore, the nurse should notify the provider about this finding.

Choice B. Blood pressure
Reason: The blood pressure of the patient is 110/76 mm Hg, which falls within the normal range (90/60 mm Hg to 120/80 mm Hg). Therefore, there is no need for the nurse to notify the provider about the patient's blood pressure.

Choice C. Hematocrit
Reason: The hematocrit level is 43%, which is within the normal range (38.8% to 50.0% for males, and 34.9% to 44.5% for females). Therefore, there is no need for the nurse to notify the provider about the patient's hematocrit level².

Choice D. PCO2
Reason: The PCO2 level is 37 mm Hg, which is within the normal range (35 to 45 mm Hg). Therefore, there is no need for the nurse to notify the provider about the patient's PCO2 level.

A. A B. B C. C

Correct Answer is A

Explanation

Choice A: The fifth intercostal space at the midclavicular line
The point of maximal impulse (PMI), also known as the apical impulse, is usually located in the fifth intercostal space at the midclavicular line. This is the point on the precordium farthest outwards (laterally) and downwards (inferiorly) from the sternum at which the cardiac impulse can be felt.

Choice B: The first intercostal space at the sternal border
The first intercostal space at the sternal border is not typically the location of the PMI. The PMI is usually located in the fifth intercostal space at the midclavicular line.

Choice C: The second intercostal space at the sternal border
The second intercostal space at the sternal border is not typically the location of the PMI. The PMI is usually located in the fifth intercostal space at the midclavicular line.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits A nurse is collecting data from a client following a thoracentesis. The nurse should notify the provider for which of the following findings? (Click on the "Exhibit" button for additional information about the client There are three tabs that contain separate categories of data.)

Correct Answer is A

Explanation

A nurse is collecting data from a client during a routine physical exam. Which of the following locations should the nurse identify as the point of maximum impulse?

Correct Answer is A

Explanation

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