During the admission assessment to the hospital, a male client reports that he is allergic to latex, penicillin, and bananas. Which intervention should the nurse implement first?

Send a list of medication allergies to the pharmacy.

Secure an allergy bracelet around the client's wrist.

Notify the dietary department of the client's fruit allergy.

Place a latex-free supply cart outside the client's room.

Answer and Explanation

The Correct Answer is B

A. Sending a list of medication allergies to the pharmacy is important for preventing adverse drug reactions but is not the immediate priority upon admission.
B. Securing an allergy bracelet around the client's wrist is the first action to ensure that all healthcare providers are immediately aware of the client's allergies, which is crucial for preventing accidental exposure to allergens.
C. Notifying the dietary department is important to prevent allergic reactions from food, but addressing the most immediate concern ensuring the client’s allergies are known to all involved in their care is a higher priority.
D. Placing a latex-free supply cart outside the room is important for preventing latex exposure but is secondary to ensuring that the client’s allergies are clearly communicated through an allergy bracelet.

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Correct Answer is B

Explanation

A. While applying a barrier ointment is important for preventing further skin breakdown, it does not address the immediate need to assess the severity of existing damage.
B. Determining the size and depth of skin breakdown is crucial for assessing the severity of the pressure injury and planning appropriate treatment. Accurate assessment helps in selecting the right interventions and monitoring the progression of the wound.
C. Completing a functional assessment of the client's self-care abilities is important for overall care planning but should follow the initial assessment of the skin breakdown to ensure immediate needs are addressed.
D. Establishing a toileting schedule is a preventive measure for future incontinence but does not address the current skin breakdown that needs immediate assessment and treatment.

A. Hand tremors. B. Shuffling gait. C. Urinary incontinence. D. Diminished visual acuity. E. Syncope when bending.

Correct Answer is ["A","B","D"]

Explanation

A. Hand tremors can impair the client’s ability to safely and effectively perform fine motor tasks, such as toenail care, making it necessary to assign a UAP for this task.
B. A shuffling gait suggests a mobility issue, which may make it difficult for the client to safely bend over and care for their feet, increasing the risk of falls or improper foot care.
C. Urinary incontinence does not directly impact the client’s ability to perform foot care and is not a reason to assign a UAP for this task.
D. Diminished visual acuity affects the client’s ability to see clearly, which is crucial when performing tasks like toenail care to avoid injury.
E. Syncope when bending indicates a risk of fainting, but it is not specifically related to the need for routine foot care by a UAP.

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During the admission assessment to the hospital, a male client reports that he is allergic to latex, penicillin, and bananas. Which intervention should the nurse implement first?

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Naxlex Comprehensive Predictor Exams

An older adult client is admitted to the medical unit following a fall at home. While undressing the client, the nurse observes that the client is wearing an adult diaper and skin breakdown is obvious over the sacral area. Which action should the nurse implement first?

Correct Answer is B

Explanation

The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and file the client's toenails? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

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