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 B
Explanation
A. Headache: While headaches can occur, they are not the most concerning side effect of stimulant medications.
B. Tachycardia: Stimulant medications, such as those used to treat ADHD (e.g., methylphenidate, amphetamines), increase central nervous system activity, which can lead to an increased heart rate (tachycardia).
C. Dizziness: While dizziness can occur, it is not the primary concern with stimulants.
D. Dry mouth: Dry mouth is a possible side effect but is not as clinically significant as tachycardia when monitoring for adverse effects.
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.
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