a client receives cefazolin sodium ancef via the intravenous route during the infusion the client begins exhibiting signs of an allergic reaction the
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Nursing Elites

NCLEX-PN

NCLEX PN Test Bank

1. While receiving an infusion of cefazolin sodium, the client complained of itchy skin. The nurse observed warm, flushed skin with a red rash on the arms, chest, and back. The health care provider was promptly notified.

Correct answer: D

Rationale: Accurate and objective documentation is essential during an incident report. Choice A makes an assumption of allergy based on subjective interpretation, which is not appropriate. Choice B states a conclusion without proper documentation. Choice C is incomplete as it fails to provide a detailed account of the observed symptoms. Choice D offers a precise description of the client's symptoms, actions taken, and notification of the healthcare provider, making it the most suitable documentation choice.

2. For which of the following conditions might blood be drawn to assess uric acid levels?

Correct answer: B

Rationale: Uric acid levels are commonly assessed in patients with gout. Gout is a type of arthritis caused by the buildup of uric acid crystals in the joints, leading to inflammation and pain. Monitoring uric acid levels helps in diagnosing and managing gout. Asthma, diverticulitis, and meningitis are not conditions where blood tests for uric acid levels are typically necessary. Asthma is a respiratory condition, diverticulitis involves inflammation of the digestive tract, and meningitis is an infection of the meninges in the brain and spinal cord.

3. Which of these clients should the LPN/LVN see first?

Correct answer: C

Rationale: Numbness and tingling hours or days after a cast is applied may indicate compartment syndrome and should be reported to a medical provider right away. This is a potential emergency situation that requires immediate attention to prevent complications. The other options present expected or typical symptoms related to their diagnosis, which do not require immediate intervention. Complaints related to a newly placed NG tube such as pain around the face and a plugged nose may require assessment and intervention but are not as urgent as potential compartment syndrome. Bladder spasms and blood in the foley bag post-prostatectomy are common postoperative issues that can be addressed after the client in the arm cast with potential compartment syndrome is seen. Stomach pain and itchy skin in a client with Hepatitis A are common symptoms of the condition and do not indicate an emergency situation.

4. A test that can correctly identify those who do not have a given disease is:

Correct answer: A

Rationale: The correct answer is 'specific.' Specificity refers to the ability of a test to correctly identify individuals who do not have a particular disease. In this case, when the client's lab culture report is negative for the suspected infection, a specific test would correctly identify that the client does not have the disease. 'Sensitive' (Choice B) is incorrect as sensitivity refers to the ability of a test to correctly identify individuals who do have the disease. 'Negative culture' (Choice C) is incorrect as it does not describe the test's ability but rather the result itself. 'Marginal finding' (Choice D) is irrelevant to the concept being tested in this question.

5. Nurse Ann tells nurse Christine that one of her client's status is declining but that she will do her best to juggle her other two clients. Which action is most appropriate?

Correct answer: B

Rationale: In this situation, when Nurse Ann informs Nurse Christine that a client's status is declining and she needs to attend to them, the most appropriate action for Nurse Christine is to inform their supervisor that assignments may need to be changed. By informing the supervisor, necessary adjustments can be made to ensure proper care for all clients. Offering to give medications to Nurse Ann's other two clients (choice A) may not address the underlying issue of a declining client and could lead to a delay in care. Asking other nurses for help (choice C) might not be the most efficient solution, as the supervisor is responsible for reassigning tasks. Nurse Ann continuing to care for all her assigned clients (choice D) may compromise the quality of care provided to the declining client and may spread her too thin, impacting all clients negatively.

Similar Questions

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