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 ["C","D","E"]

Explanation

A. Raising the four side rails on the bed can be considered a form of restraint and might increase the risk of injury if the client attempts to climb over them. It is not recommended unless necessary and in accordance with facility policies.
B. Closing the client's room door could increase the client's confusion and sense of isolation, making it harder for the staff to monitor the client’s safety.
C. Orienting the client to the surroundings is essential in reducing confusion and preventing further wandering. It helps the client feel more secure and less disoriented.
D. Securing a bed alarm on the mattress is a proactive safety measure that can alert the staff if the client attempts to leave the bed again, thus preventing potential harm.
E. Escorting the client back to her room ensures immediate safety and provides an opportunity to assess the client's condition and needs in a controlled environment.

A. Notify the information services department of the situation. B. Print electronic medical record (EMR) from the backup server. C. Identify information as a late entry in the record. D. Wait for notification that the system has been rebooted.

Correct Answer is A

Explanation

A. The first priority is to notify the information services department to address the technical issue with the computer system. This ensures that the problem is being handled and allows the nurse to focus on immediate patient care needs.
B. Printing the EMR from the backup server is not possible until the issue with the computer system is resolved. Immediate reporting to IT is necessary to address the technical problem first.
C. Identifying information as a late entry is premature and not the immediate priority. Ensuring the functionality of the electronic system is crucial before making manual records.
D. Waiting for the system to reboot does not address the immediate need for technical support and may delay patient care.

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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

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