Moderate

A patient states that she is allergic to penicillin, but the medication record says no known allergies. What should the nurse do first?

Correct answer: B. Ask the patient to describe the previous reaction

  • A. Administer the prescribed antibiotic as recorded
  • B. Ask the patient to describe the previous reaction
  • C. Delete the allergy entry from the medication record
  • D. Ask a family member to decide which record is correct

Explanation

The nurse should validate the discrepancy by asking what happened, when it occurred and how severe the reaction was. The antibiotic should not be given until the allergy information is clarified and documented appropriately.

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About Nursing Process and Health Assessment

Assessment gathers subjective and objective data through health history, physical examination and observation. The nursing process then uses nursing diagnoses, planning, implementation and evaluation to provide individualised care, while distinguishing a nursing diagnosis from a medical diagnosis and identifying priorities such as airway, breathing, circulation and safety.

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