The client states they have an allergy to codeine. Which is the best response by the nurse?
Ignore the comment and document the NKA.
Why do you think this is an allergy?
Don’t worry, if you take it with food, you will be okay.
What symptoms do you experience with codeine?
The Correct Answer is D
Choice A rationale
Ignoring the comment and documenting “No Known Allergies” (NKA) is incorrect because it disregards the client’s report of an allergy. This action could lead to potential harm if the client is indeed allergic to codeine.
Choice B rationale
Asking the client why they think it is an allergy is not the best response. It may come across as dismissive and does not provide the nurse with specific information about the client’s allergic reaction.
Choice C rationale
Telling the client not to worry and that they will be okay if they take codeine with food is incorrect. This response is dismissive of the client’s concern and does not address the potential for an allergic reaction.
Choice D rationale
Asking the client what symptoms they experience with codeine is the best response. It allows the nurse to gather specific information about the client’s allergic reaction, which is crucial for safe medication administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Fatigue is a subjective symptom reported by the client. It is based on the client’s personal experience and cannot be objectively measured or observed by the nurse. Therefore, it is not considered objective data.
Choice B rationale
Dizziness is also a subjective symptom reported by the client. It reflects the client’s personal experience and cannot be directly observed or measured by the nurse. As such, it is not considered objective data.
Choice C rationale
Numbness is another subjective symptom reported by the client. It is based on the client’s personal sensation and cannot be objectively measured or observed by the nurse. Therefore, it is not considered objective data.
Choice D rationale
Physical examination results are objective data. They are obtained through direct observation, measurement, and assessment by the nurse. Examples of objective data include vital signs, physical examination findings, and laboratory results. These data are reproducible and can be verified by other healthcare professionals.
Correct Answer is D
Explanation
Choice A rationale
“The client will be able to perform daily activities independently.”. This goal is not specific or time-bound. It does not provide a clear timeframe or measurable criteria for achieving the goal.
Choice B rationale
“The client’s pain will be managed effectively.”. This goal is not specific or measurable. It does not provide clear criteria for what constitutes effective pain management or a timeframe for achieving the goal.
Choice C rationale
“The client states he feels better.”. This goal is not specific, measurable, or time-bound. It does not provide clear criteria for what “feeling better” means or a timeframe for achieving the goal.
Choice D rationale
“The client will be able to walk one mile on post-op day 2 after knee surgery.”. This goal is a SMART goal as it is Specific, Measurable, Achievable, Relevant, and Time-bound. It provides clear criteria for what the client should achieve and a specific timeframe for achieving it.
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