The nurse administers a medication to a patient. Shortly afterward, the patient develops an itchy rash all of his body and reports feeling very unwell. What is the priority action of the nurse?
a. Leave the patient to notify the physician and the pharmacist.
b. Determine if the patient is having any difficulty breathing.
c. Document the reaction in the patient's chart.
d. Obtain an order for hydrocortisone cream to relieve the itching.
ANS: B
The nurse must first determine if the patient is having any difficulty breathing, since the patient may be starting to have an anaphylactic reaction to the medication. Anaphylaxis is life threatening and requires immediate treatment; the nurse must recognize this potential and plan to initiate emergency interventions right away.
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The nurse providing medication through a client's nasogastric tube should flush the port to:
a. prevent aspiration of medication. c. prevent clogging of the tube. b. dilute the medication. d. increase the water intake.
Genetic testing indicates that a child has DR3 and DR4 antigens on chromosome 6 of the human leukocyte antigen system. Which statement by the parents would indicate the nurse should reinforce teaching about these test results?
1. "Our son has a genetic immunity disorder.". 2. "These results mean our son has diabetes.". 3. "These markers are present in 95% of people with type 1 diabetes.". 4. "These results are associated with increased susceptibility to diabetes.".
List three causes of artifact on an ECG tracing
What will be an ideal response?
While counseling a patient about the optimum use of sunscreens, the nurse should include what information? "Apply the sunscreen
a. when you are first exposed to the sun." b. only to your body; do not apply it to your face." c. only to areas that have burned in the past." d. at least 30 minutes before exposure to the sun."