What information would the nurse document regarding a patient's reported allergies? Select all that apply.
Family history of allergies.
Type of allergic reaction.
Medication names.
Epi Pen use for allergic reactions.
Date of allergic reaction.
Correct Answer : B,C,D,E
Choice A rationale
Documenting a family history of allergies is important for a complete health history, but it is not a direct documentation of the patient's own reported allergies. The question asks what information to document regarding a patient's reported allergies, so the focus is on the patient's personal experience, not that of their family.
Choice B rationale
The type of allergic reaction is crucial information to document. This helps in distinguishing between a true anaphylactic reaction and a side effect or intolerance. Documenting the specific signs and symptoms, such as rash, hives, or shortness of breath, provides vital information for preventing future exposures and guiding appropriate treatment if one occurs.
Choice C rationale
The medication names are essential to document to prevent future exposure to the same drug. This ensures that the patient does not receive the offending medication again, which is a primary safety measure. It is a fundamental component of a complete allergy record to specify the substance that caused the reaction.
Choice D rationale
Documentation of Epi Pen use is critical as it indicates a severe, anaphylactic reaction requiring an emergency intervention. This information alerts providers to the high risk of a life-threatening allergic response and the need for preparedness, such as having epinephrine available for future exposure.
Choice E rationale
The date of the allergic reaction should be documented to provide a chronological history. This helps in understanding the timeline of the allergy and can be useful for determining if an allergy has changed over time or for correlating the reaction with a specific exposure
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Impetigo is a bacterial skin infection caused by Staphylococcus aureus or Streptococcus pyogenes. Steroids have immunosuppressive properties and can exacerbate bacterial infections by hindering the body’s ability to fight off the pathogens. Therefore, steroid creams are contraindicated and would not effectively treat the sores, as they would likely worsen the condition and delay healing.
Choice B rationale
The statement indicates an understanding of the importance of completing the full course of antibiotics to eradicate all of the bacteria. Discontinuing the medication prematurely can lead to antibiotic resistance and a recurrence of the infection, as some of the bacteria may survive and proliferate. Finishing the entire prescription ensures complete elimination of the pathogens.
Choice C rationale
Impetigo sores should not be covered with a tight dressing, as this can trap moisture and heat, creating an ideal environment for bacterial growth and proliferation. While the sores should be kept clean and dry, covering them daily with an occlusive dressing is generally not recommended. This can worsen the infection and hinder the drying and healing process.
Choice D rationale
Impetigo is highly contagious, but it is primarily spread through direct contact with the sores. While thumb sucking could potentially transfer bacteria from the hands to the face, it is not the primary route of transmission or a specific treatment concern. The focus should be on proper hand hygiene and avoiding scratching or picking at the lesions, which is the main way the infection spreads.
Correct Answer is C
Explanation
Choice A rationale
Placing one hand on the fundus while the other is on the perineum is an incorrect technique. This method fails to provide counterpressure to the lower uterine segment, which is essential to prevent uterine inversion during fundal massage. The uterus must be stabilized to ensure safe and effective palpation and massage.
Choice B rationale
Palpating the fundus with only fingertip pressure is an incorrect technique. This light pressure is insufficient to accurately assess uterine tone and position. Effective palpation requires firm but gentle pressure to compress the uterine wall and determine its height, tone, and midline placement.
Choice C rationale
Placing one hand at the base of the uterus just above the symphysis pubis and one on the fundus is the recommended technique. This provides essential counterpressure to support the lower uterine segment and prevent uterine prolapse or inversion during palpation and massage, ensuring patient safety.
Choice D rationale
Resting both hands on the fundus is an incorrect technique. This method fails to provide adequate counterpressure to the lower uterine segment. Without this stabilization, there is an increased risk of uterine inversion when massaging or assessing the fundus, a potentially life-threatening complication.
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