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 ["B","D","E"]
Explanation
Choice A reason: Aspirin is an antiplatelet agent and may not be recommended immediately postprostatectomy due to the risk of bleeding.
Choice B reason: Patients should avoid lifting heavy objects postprostatectomy to prevent strain on the surgical site.
Choice C reason: Resuming sexual intercourse should be discussed with the healthcare provider, as it typically requires a longer recovery period.
Choice D reason: Showering is recommended over taking a tub bath to prevent infection at the surgical site.
Choice E reason: Observing blood in the urine after coughing may occur as the surgical area heals, but it should be monitored for any signs of complications.
Correct Answer is B
Explanation
Choice A reason: Chest pain is not a typical symptom of opioid toxicity. Opioids generally have a depressant effect on the body, which does not usually manifest as chest pain.
Choice B reason: Hypotension is a common finding in opioid toxicity due to the depressant effects opioids have on the autonomic nervous system.
Choice C reason: Pupillary dilation is not expected with opioid toxicity; instead, opioids typically cause miosis, which is the constriction of the pupils.
Choice D reason: Diaphoresis, or excessive sweating, can occur with opioid toxicity as part of the body's response to the substance.
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