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.
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Related Questions
Correct Answer is D
Explanation
A. The client will verbalize 3 positive attributes about themselves by day 3. This is a good long-term goal but does not directly prevent self-harm.
B. The client will perform personal hygiene with no prompting. Improved self-care is beneficial but is not the primary priority in suicide prevention.
C. The client will attend group by day 2. Participation in therapy is helpful, but ensuring physical safety takes precedence.
D. The client will remain free from injury for the duration of their hospitalization. The most critical goal for a client at risk for suicide is preventing self-harm, making this the priority outcome.
Correct Answer is C
Explanation
A. Hypertension: Blood loss leads to hypovolemia, which usually causes hypotension, not hypertension.
B. Hypothermia: While hypothermia can occur postoperatively, it is not the most direct result of blood loss.
C. Tachycardia: Blood loss leads to decreased circulating volume, triggering tachycardia as a compensatory response to maintain oxygen delivery.
D. Bradypnea: Severe blood loss is more likely to cause tachypnea (rapid breathing) rather than slow respirations.
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