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 ["1.5"]
Explanation
Step 1: Calculate the total amount of heparin needed per dose:
15,000 units ÷ 10,000 units/mL = 1.5 mL
1.5 mL of heparin with each dose.
Correct Answer is D
Explanation
Choice A reason: Canned soup often contains high levels of sodium, which is not recommended for individuals with hypertension.
Choice B reason: Ketchup is typically high in sodium and should be used sparingly by individuals with hypertension.
Choice C reason: Bologna is a processed meat that is usually high in sodium and should be avoided by those with hypertension.
Choice D reason: Vinegar is a low sodium seasoning option that can be used to add flavor without increasing blood pressure.
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