Thirty minutes after receiving meperidine, the client develops a temperature of 101°F and the skin is warm and flushed with a notable rash on the chest and back. The nurse contacts the primary health care provider and begins to document on an incident report. Which information should be included?
The client had an allergic reaction to the ordered meperidine.
The primary health care provider was notified because the client developed a rash after receiving an opioid analgesic.
The client’s skin was warm and flushed, and a rash was noted on the chest and back.
Thirty minutes after receiving meperidine, the temperature was 101°F (38.3°C).
The Correct Answer is D
Choice A rationale
Stating that the client had an allergic reaction to the ordered meperidine is not objective and does not provide specific details about the client’s condition.
Choice B rationale
Notifying the primary health care provider because the client developed a rash after receiving an opioid analgesic is important, but it does not include all the necessary details about the client’s condition.
Choice C rationale
Documenting that the client’s skin was warm and flushed, and a rash was noted on the chest and back is important, but it does not include the timing of the reaction or the client’s temperature.
Choice D rationale
Documenting that thirty minutes after receiving meperidine, the temperature was 101°F (38.3°C), the client’s skin was warm and flushed, and a rash was noted on the chest and back provides a complete and objective account of the client’s condition and the timing of the reaction.
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Correct Answer is B
Explanation
Choice A rationale
Timolol is a beta-blocker used to reduce intraocular pressure in patients with open-angle glaucoma. It is not intended for short-term use or gradual tapering off. The medication must be used consistently to maintain its therapeutic effect.
Choice B rationale
Timolol should be applied on a regular schedule for the rest of the client’s life to effectively manage intraocular pressure and prevent further damage to the optic nerve.
Choice C rationale
Timolol does not cure glaucoma or normalize intraocular pressure permanently. Continuous use is necessary to control the condition.
Choice D rationale
Timolol is not used as a pain reliever. It is specifically prescribed to manage intraocular pressure in glaucoma patients.
Correct Answer is B
Explanation
Choice A rationale
Rephrasing statements the client does not hear is helpful but not the priority action. The priority is to determine if the client uses hearing aids to ensure they can hear instructions and communication effectively.
Choice B rationale
Determining if the client uses hearing aids is the priority action. Ensuring the client has and uses their hearing aids can significantly improve communication and care.
Choice C rationale
Speaking using the usual tone of voice and directly in front of the client is important but secondary to ensuring the client has their hearing aids.
Choice D rationale
Using hand gestures to communicate can be helpful but is not the priority action. The primary focus should be on ensuring the client has their hearing aids for optimal hearing.