A patient tells the nurse that he is allergic to penicillin. What would be the nurse’s best response to this information?
Are you allergic to any other drugs?
How often have you received penicillin?
Describe what happens to you when you take penicillin
I’ll write your allergy on your chart so you won’t receive any penicillin
The Correct Answer is C
Choice A reason: Asking about other drug allergies is relevant but secondary to understanding the penicillin allergy’s nature. Without clarifying the reaction’s severity (e.g., anaphylaxis vs. rash), the nurse cannot fully assess the risk, making this a less immediate response.
Choice B reason: Asking about the frequency of penicillin use does not address the nature or severity of the allergic reaction. This information is irrelevant to managing the allergy and ensuring patient safety, making it an inappropriate initial response.
Choice C reason: Asking the patient to describe their reaction to penicillin clarifies the type and severity of the allergy (e.g., rash, anaphylaxis). This informs safe medication administration and prevents adverse reactions, making it the most critical and appropriate response.
Choice D reason: Documenting the allergy is necessary but premature without understanding the reaction’s specifics. Assuming the allergy without verification could lead to incomplete charting or mismanagement, making this a less priority response compared to gathering details.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Inspection is the primary technique to further assess a raw, inflamed throat, allowing visualization of color, swelling, or lesions. This non-invasive method is appropriate, making it the correct choice for throat assessment.
Choice B reason: Palpation is inappropriate for a raw throat, as it may cause pain or spread infection. Inspection visually evaluates inflammation, so this is incorrect for further assessment.
Choice C reason: Percussion is used for chest or abdomen, not throat assessment. Visual inspection is needed for inflamed throat tissue, so this is incorrect for the technique required.
Choice D reason: Auscultation is for sounds (e.g., lungs), not visual throat changes. Inspection allows direct observation of inflammation, so this is incorrect for assessing throat condition.
Correct Answer is C
Explanation
Choice A reason: The S2 sound is produced by the closure of aortic and pulmonic valves, not tricuspid and aortic. Tricuspid closure contributes to S1, so this is incorrect for the S2 heart sound.
Choice B reason: Mitral and tricuspid valve closure produce the S1 sound, not S2. Aortic and pulmonic valves close during diastole, creating S2, so this incorrect for the second heart sound.
Choice C reason: The S2 sound results from the closure of the aortic and pulmonic valves at the end of systole, marking diastole’s start. This is the standard mechanism, making it the correct choice for S2.
Choice D reason: Pulmonic and mitral valves don’t close simultaneously; mitral closes for S1, pulmonic for S2. Aortic and pulmonic valves form S2, so this is incorrect for the heart sound.
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