Which is the priority action by the nurse when a patient discloses a medication allergy during the health history before a surgical procedure?

Verifying the information with the patient's family members at the bedside

Placing an alert bracelet on the patient before leaving the unit

Asking the patient to describe the reaction that occurs

Documenting the information on the patient's medical record

Answer and Explanation

The Correct Answer is C

A. Verifying the information with the patient's family members at the bedside: While family members can provide insight, the most critical step is gathering information directly from the patient about the reaction.

B. Placing an alert bracelet on the patient before leaving the unit: While this is necessary, the nurse should first confirm the details of the allergy.

C. Asking the patient to describe the reaction that occurs: The nurse must determine whether the reaction is a true allergy (e.g., anaphylaxis, rash, difficulty breathing) or an intolerance (e.g., nausea, drowsiness). This ensures appropriate precautions are taken.

D. Documenting the information on the patient's medical record: Documentation is crucial but should follow verification of the allergy details.

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Correct Answer is D

Explanation

A. Numbness of fingers. Numbness or tingling (paresthesia) is more common in respiratory alkalosis due to low CO₂ levels causing calcium binding changes.

B. Dry skin. Respiratory acidosis does not typically cause dry skin; rather, it may cause cyanosis or flushed skin due to CO₂ retention.

C. Abdominal pain. Abdominal pain is more commonly seen in metabolic acidosis, not respiratory acidosis.

D. Lethargy. Respiratory acidosis leads to CO₂ retention, which depresses the central nervous system, causing lethargy, confusion, and even coma in severe cases.

A. Inability to void without fluid retention B. Persistent nausea without vomiting C. Lethargy that resolves after several hour D. Pain management with opioid analgesics

Correct Answer is A

Explanation

A. Inability to void without fluid retention. Urinary retention is a common post-op complication, especially after anesthesia, and requires monitoring to prevent bladder distension or kidney issues.

B. Persistent nausea without vomiting. Nausea can be managed with antiemetics and does not necessarily require prolonged monitoring.

C. Lethargy that resolves after several hours. Post-anesthesia drowsiness is expected and does not necessarily indicate a need for extended observation.

D. Pain management with opioid analgesics. Pain control with opioids is expected and does not, by itself, require extended monitoring.

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Which is the priority action by the nurse when a patient discloses a medication allergy during the health history before a surgical procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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