You are doing a shift assessment on your patients after first taking report. An elderly patient is having her second dose of IV antibiotics for a diagnosis of pneumonia. The nurse notices a new reddened rash on the patient's chest
The patient should be asked what priority question regarding the presence of a reddened rash?
A) Is the rash worse at a particular time or season?
B) Are you allergic to any food or medication?
C) Is there any loss of sensation?
D) What is your occupation?
Ans: B
Feedback: The nurse should suspect an allergic reaction to the antibiotic therapy.
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An 81-year-old patient who has been in the intensive care unit (ICU) for a week is now stable and transfer to the progressive care unit is planned. On rounds, the nurse notices that the patient has new onset confusion. The nurse will plan to
a. give PRN lorazepam (Ativan) and cancel the transfer. b. inform the receiving nurse and then transfer the patient. c. notify the health care provider and postpone the transfer. d. obtain an order for restraints as needed and transfer the patient.
Which of the following diagnostic tests indicates that a patient has a fluid volume deficit? Select all that apply
1. Elevated urine specific gravity 2. Decreased hemoglobin level 3. High hematocrit level 4. Elevated blood urea nitrogen (BUN) 5. Elevated red blood cell count
A postpartum woman is complaining of a headache that is worsening despite having taken Tylenol (acetaminophen) an hour ago. She delivered yesterday with epidural anesthesia. What action by the nurse is best?
A. Assess if the pain is worse when she sits upright. B. Call the provider and ask for stronger analgesics. C. Document the findings in the patient's chart. D. Notify the health-care provider immediately.
A novice nurse attends a lecture regarding risk management. Which action should the nurse implement to reduce risks in practice?
A) Not discussing errors made B) Questioning every order that the physician writes C) Purchasing liability insurance D) Storing unused equipment in the halls of the unit