what is the nurses priority action when a patient is experiencing an allergic reaction to a medication
Logo

Nursing Elites

ATI RN

ATI Capstone Comprehensive Assessment B

1. What is the priority action when a patient is experiencing an allergic reaction to a medication?

Correct answer: B

Rationale: The correct answer is to discontinue the medication and notify the healthcare provider when a patient is experiencing an allergic reaction to a medication. This action is crucial to prevent further harm to the patient. Monitoring blood pressure (choice A) or urine output (choice D) may be important but is not the priority when managing an allergic reaction. Administering an antihistamine (choice C) should only be done after discontinuing the medication and consulting with the healthcare provider.

2. After placing the patient back in bed, what should the nurse do next?

Correct answer: C

Rationale: After placing the patient back in bed, the nurse should notify the health care provider. This is important because the health care provider needs to be informed of the incident and assess the patient further to ensure no underlying injuries or issues exist. Re-assessing the patient is crucial but notifying the health care provider takes precedence in this situation. Completing an incident report is important for documentation purposes but not the immediate next step. Doing nothing is incorrect as there was an incident involving a fall that needs further evaluation.

3. A nurse enters a client's room to administer a prescribed medication, and the client asks about the medication. What is the most appropriate response by the nurse?

Correct answer: B

Rationale: The most appropriate response for the nurse when a client asks about a medication is to refer the client to the healthcare provider for more information. This ensures that the client receives accurate and detailed information from the appropriate source. Providing detailed information or a brief explanation as choices A and C suggest may not be within the nurse's scope of practice and could potentially lead to misinformation or confusion. Asking another nurse to explain the medication, as in choice D, may not guarantee accurate information, so it is best to involve the healthcare provider directly.

4. A patient requires assistance to stand from a sitting position. Which action by the nurse ensures patient safety?

Correct answer: B

Rationale: The correct answer is B. Placing a gait belt around the patient for support is the safest option when assisting a patient to stand from a sitting position. This belt provides stability and support, reducing the risk of falls or injuries during the transfer. Choices A, C, and D are incorrect. Allowing the patient to pull up on the nurse's arm (Choice A) may lead to instability and compromise safety. Having the patient push off the chair with their hands (Choice C) might not provide sufficient support, especially for patients who require assistance. Asking the patient to lift themselves up without support (Choice D) can be dangerous and increase the risk of falls.

5. A nurse is assessing a postoperative patient for signs of infection. Which finding is most concerning?

Correct answer: C

Rationale: A fever of 101°F is the most concerning finding when assessing a postoperative patient for signs of infection. Fever can indicate an inflammatory response to an infection, and in a postoperative patient, it can signal a surgical site infection or a systemic infection. Prompt attention is necessary to prevent complications such as sepsis. Mild redness at the incision site and increased drainage can be expected in the early postoperative period due to the normal healing process. A normal white blood cell count does not rule out infection as it can be influenced by various factors, and some infections may not initially cause a rise in white blood cells.

Similar Questions

What is the recommended procedure for a healthcare professional to follow when applying sterile gloves?
What is the most appropriate intervention for a client experiencing acute alcohol withdrawal?
While caring for a client receiving morphine, what assessment is the priority for a nurse to conduct?
A nurse is caring for a patient with heart failure who has developed pulmonary edema. What is the nurse's priority action?
A healthcare provider orders a medication dose three times higher than usual. What is the nurse's first step?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses