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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Financial stability: Financial stability is a protective factor against suicide.
B. Engaging in extracurricular activities: Social involvement and participation in activities generally reduce suicide risk.
C. Loss of a job: Job loss is a significant psychosocial stressor that can contribute to feelings of hopelessness, depression, and suicidal ideation.
D. Exercising caution in behavior: Individuals at risk for suicide often engage in impulsive or risky behavior, not cautious behavior.
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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