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

Explanation

A. While it is important to address unprofessional behavior, directly warning the colleague may not be sufficient to address the breach of security protocols effectively.
B. Discussing the action at a staff meeting may not address the immediate issue and could lead to general discussions rather than specific corrective actions.
C. Communicating the observation to the charge nurse is appropriate because it ensures that the issue is reported to a person who can take immediate action to address the breach of EHR security and prevent further unauthorized access.
D. Filing a detailed incident report may be necessary, but first, informing the charge nurse is crucial for immediate action and to address the issue promptly. The charge nurse can then guide the next steps, including filing a report if necessary.

A. Keep the medication and see if the client will want to take it later. B. Credit the medication back and put it in the client's medication box. C. Explain that since the medication is a controlled substance it must be taken. D. Have another nurse watch the disposal of the medication into the disposal container.

Correct Answer is D

Explanation

A. The medication should not be kept or stored once it has been removed from its original packaging, especially if it’s not administered. Proper disposal or return to the pharmacy is required.
B. The medication should not be put back in the client’s medication box due to safety and contamination concerns.
C. While controlled substances need careful management, the client’s refusal must be respected, and the medication must be disposed of properly if not administered.
D. Having another nurse witness the disposal of the medication ensures that it is done according to protocols and provides accountability. This practice helps maintain the integrity and safety of medication handling.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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