After administering a medication, the nurse notes that the client has itching and a runny nose. What is the nursing priority?
1. Document the findings.
2. Assess vital signs.
3. Notify the charge nurse.
4. Monitor the client closely.
Correct Answer: 3
Rationale 1: Document the findings is incorrect because on discovering that a client is allergic to a product, it is the nurse's responsibility to first alert the charge nurse and patient's physician. Documentation is next as well as to apply labels to the chart and medication administration record to alert all healthcare personnel of the allergy. The client should be given an agency-approved allergy bracelet, and the pharmacist should also be told.
Rationale 2: Assess vital signs is incorrect because vital signs may or may not be assessed in this situation, and it would not be the next action of the nurse.
Rationale 3: On discovering that a client is allergic to a product, it is the nurse's responsibility to first alert the charge nurse and patient's physician.
Rationale 4: Monitor the client closely is incorrect because in this situation the client is stable; however, the client would be monitored after notifying the charge nurse, physician, pharmacist, and documenting information in the client's medical record.
Global Rationale: On discovering that a client is allergic to a product, it is the nurse's responsibility to first alert the charge nurse and patient's physician. Document the findings is incorrect because on discovering that a client is allergic to a product, it is the nurse's responsibility to first alert the charge nurse and patient's physician. Documentation is next as well as to apply labels to the chart and medication administration record to alert all healthcare personnel of the allergy. The client should be given an agency-approved allergy bracelet, and the pharmacist should also be told. Assess vital signs is incorrect because vital signs may or may not be assessed in this situation, and it would not be the next action of the nurse. Monitor the client closely is incorrect because in this situation the client is stable, however, the client would be monitored after notifying the charge nurse, physician, pharmacist and documenting information in the client's medical record.
You might also like to view...
When accessing a client's record, the nursing student is careful to
1. Use the instructors password 2. Turn the monitor around when walking away from the computer 3. Leave notes and information in the facility's receptacle for papers containing PHI when finished for the day 4. Allow only the client's family to see the notes
Once the do not resuscitate (DNR) decision has been made, the order should be
A) witnessed by the charge nurse. B) written, signed, and dated by the physician. C) posted at the head of the patient's bed. D) made known to all the family members.
A researcher designs a study to measure whether receiving a free season pass to a beautiful ski resort near Bountiful, Utah, increases the number of days a subject who has lived in the area for 1 to 3 years skis during the season
An independent samples t-test of correlation is used to measure the effect of receiving a season pass upon number of ski days. If, instead, the researcher decided to measure the subjects' responses by asking them to check one of these four replies on a survey, "Much more often than last year," "More often than last year," "Just about the same as last year," or "Less often than last year," why would the independent samples t-test have to be abandoned for a Mann-Whitney U test instead? (Select all that apply.) a. The variable of skiing is measured at the nominal instead of the ratio level. b. The variable of skiing is now measured at the ordinal instead of ratio level. c. The variable amount skied is now measured at the nominal level instead of the ratio level. d. The variable amount skied is now measured at the ordinal level instead of the ratio level. e. Both variables' levels have changed. f. The independent samples t-test used demands ratio-level or interval-level data. g. The Mann-Whitney U test allows for ordinal level values, but not nominal.
Which statement indicates that the client needs more teaching about mucositis?
a. "I will rinse my mouth with water after every meal." b. "I will use a soft-bristled toothbrush to prevent trauma." c. "I should use an alcohol-based mouth rinse to kill bacteria." d. "I cannot use floss because it may irritate my gums."