Thirty minutes after receiving meperidine, the client develops a temperature of 101°F and the skin is warm and flushed with a notable rash on the chest and back.

The nurse contacts the primary health care provider and begins to document on an incident report.

Which information should be included?

The client had an allergic reaction to the ordered meperidine.

The primary health care provider was notified because the client developed a rash after receiving an opioid analgesic.

The client’s skin was warm and flushed, and a rash was noted on the chest and back.

Thirty minutes after receiving meperidine, the temperature was 101°F (38.3°C).

Answer and Explanation

The Correct Answer is D

Choice A rationale

Stating that the client had an allergic reaction to the ordered meperidine is not objective and does not provide specific details about the client’s condition.

Choice B rationale

Notifying the primary health care provider because the client developed a rash after receiving an opioid analgesic is important, but it does not include all the necessary details about the client’s condition.

Choice C rationale

Documenting that the client’s skin was warm and flushed, and a rash was noted on the chest and back is important, but it does not include the timing of the reaction or the client’s temperature.

Choice D rationale

Documenting that thirty minutes after receiving meperidine, the temperature was 101°F (38.3°C), the client’s skin was warm and flushed, and a rash was noted on the chest and back provides a complete and objective account of the client’s condition and the timing of the reaction.

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Correct Answer is C

Explanation

Choice A rationale

Dysphagia, or difficulty swallowing, is not a common manifestation of acoustic neuroma. It is more commonly associated with conditions affecting the throat or esophagus.

Choice B rationale

Apraxia, a motor disorder caused by damage to the brain, is not typically associated with acoustic neuroma. It affects the ability to perform coordinated movements.

Choice C rationale

Vertigo, or a sensation of spinning, is a common manifestation of acoustic neuroma. The tumor affects the vestibular nerve, which is responsible for balance and spatial orientation.

Choice D rationale

Diplopia, or double vision, is not a common symptom of acoustic neuroma. It is more often associated with conditions affecting the muscles or nerves controlling eye movement.

A. Apply a non-pressure patch to the affected eye. B. Clean the eye from inner to outer canthus. C. Notify the surgeon. D. Instill an antibiotic solution in both eyes.

Correct Answer is C

Explanation

Choice A rationale

Applying a non-pressure patch to the affected eye can help protect the eye from further irritation or injury. However, it does not address the underlying issue of purulent drainage, which could indicate an infection that requires immediate medical attention.

Choice B rationale

Cleaning the eye from inner to outer canthus is a standard practice to prevent the spread of infection. However, in this case, the presence of purulent drainage suggests a possible infection that needs to be evaluated by a surgeon.

Choice C rationale

Notifying the surgeon is the priority action because purulent drainage from the eye can indicate a serious infection or complication following surgery. Immediate medical evaluation and intervention are necessary to prevent further complications and ensure proper treatment.

Choice D rationale

Instilling an antibiotic solution in both eyes may be part of the treatment plan for an infection. However, the nurse should first notify the surgeon to get appropriate orders and ensure that the correct antibiotic and treatment plan are followed.

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Thirty minutes after receiving meperidine, the client develops a temperature of 101°F and the skin is warm and flushed with a notable rash on the chest and back. The nurse contacts the primary health care provider and begins to document on an incident report. Which information should be included?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has an acoustic neuroma. Which of the following client manifestations should the nurse expect?

Correct Answer is C

Explanation

A nurse is caring for a client who is postoperative following a left corneal transplant. The nurse observes purulent drainage from the affected eye. Which of the following actions is the nurse’s priority?

Correct Answer is C

Explanation

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