A nurse working on a medical unit is completing the admission of a client who reports a severe allergy to penicillin. Which of the following actions should the nurse take?

Remove all objects that contain latex from the client’s room.

Verify the client’s medication prescriptions do not include cephalosporin.

Notify dietary services to adjust the client’s diet.

Have the client purchase a medication alert bracelet to wear in the hospital.

Answer and Explanation

The Correct Answer is B

Choice A reason:

Removing all objects that contain latex from the client’s room is important for clients with a latex allergy, not a penicillin allergy. Latex allergies can cause severe reactions, including anaphylaxis, but this action is not relevant to a penicillin allergy.

Choice B reason:

Verifying that the client’s medication prescriptions do not include cephalosporin is crucial because cephalosporins can have cross-reactivity with penicillin. Clients with a penicillin allergy may also react to cephalosporins, so it is essential to avoid prescribing these antibiotics.

Choice C reason:

Notifying dietary services to adjust the client’s diet is not directly related to managing a penicillin allergy. Dietary adjustments are more relevant for clients with food allergies or specific dietary restrictions.

Choice D reason:

Having the client purchase a medication alert bracelet to wear in the hospital is a good practice for general safety, but it is not an immediate action the nurse should take during the admission process. The primary focus should be on ensuring that the client’s medications do not include penicillin or related antibiotics.

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Correct Answer is A

Explanation

Choice A reason:

0730: Regular insulin, also known as short-acting insulin, typically begins to work within 30 minutes after administration. Therefore, ensuring the client receives breakfast at 0730, which is 15 minutes after the insulin dose, aligns with the onset of insulin action. This timing helps to prevent hypoglycemia by ensuring that glucose from the meal is available when the insulin starts to lower blood sugar levels.

Choice B reason:

0745: Administering breakfast at 0745, which is 30 minutes after the insulin dose, might be slightly delayed. While it is still within the effective window, it is better to have the meal a bit earlier to ensure that glucose is available as soon as the insulin begins to act.

Choice C reason:

0815: Providing breakfast at 0815, which is an hour after the insulin dose, is too late. By this time, the insulin would have already started to lower blood glucose levels significantly, increasing the risk of hypoglycemia. It is crucial to match the timing of food intake with the insulin action to maintain stable blood sugar levels.

Choice D reason:

0720: Serving breakfast at 0720, which is only 5 minutes after the insulin dose, is too early. The insulin would not have started to act yet, and the blood glucose levels might rise too high before the insulin begins to lower them. It is important to wait at least 15-30 minutes after administering regular insulin before eating.

A. Distorted perceptual field. B. Urinary frequency. C. Rapid speech.

Correct Answer is C

Explanation

Choice A reason:

Distorted perceptual field is more commonly associated with severe anxiety or panic attacks rather than moderate anxiety. In severe anxiety, a person’s ability to perceive reality can be significantly impaired, leading to distorted perceptions and an inability to focus.

Choice B reason:

Urinary frequency can be a symptom of anxiety, but it is not specifically indicative of moderate anxiety. It can occur in various levels of anxiety, including mild, moderate, and severe. However, it is not as prominent a symptom as others like rapid speech or restlessness.

Choice C reason:

Rapid speech is a common symptom of moderate anxiety. Individuals with moderate anxiety often exhibit signs of increased nervousness and agitation, which can manifest as rapid or pressured speech. This symptom reflects the heightened state of arousal and the difficulty in controlling anxious thoughts.

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A nurse working on a medical unit is completing the admission of a client who reports a severe allergy to penicillin. Which of the following actions should the nurse take?

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A nurse working on a medical unit is completing the admission of a client who reports a severe allergy to penicillin. Which of the following actions should the nurse take?