Nokea
A client has a nursing diagnosis of Ineffective Airway Clearance. Which of the following would the nurse include in the client's plan of care? Select all that apply.
- A. Encouraging increased fluid intake
- B. Assisting the client in taking deep, diaphragmatic breaths
- C. Discouraging client movement
- D. Instructing the client to avoid coughing
- E. Encouraging the client to change positions
Correct Answer: A,B,E
Rationale: Clients should be encouraged to change positions frequently, breathe deeply, and increase fluid intake to aid in effectively clearing the airway of sputum. Coughing helps to move mucus.
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Before administering an antitussive to a client, which of the following would the nurse assess? Select all that apply.
- A. Temperature
- B. Sputum presence
- C. Type of cough
- D. Bowel sounds
- E. Heart sounds
Correct Answer: A,B,C
Rationale: Vital signs, type of cough, presence of sputum, color and amount of sputum, home remedies used, and actions taken should be assessed prior to initiation of an antitussive. Bowel and heart sounds are not part of the preadministration assessment.
Before administering an antihistamine to a client, which of the following would the nurse include in the preadministration assessment? Select all that apply.
- A. Asking about symptoms
- B. Checking visual acuity
- C. Asking about prescription medications
- D. Auscultating bowel sounds
- E. Auscultating heart sounds
Correct Answer: A,C
Rationale: The preadministration assessment for clients receiving antihistamines depends on the reason for use but should at the least include asking about symptoms of the involved areas and asking about prescription medications the client is taking.
Based on the nurse's understanding of decongestants, the nurse would expect to administer this drug cautiously to a client with which of the following? Select all that apply.
- A. Diabetes
- B. Glaucoma
- C. Hypotension
- D. Hypothyroidism
- E. Arthritis
Correct Answer: A,B
Rationale: The nurse should administer decongestants cautiously to clients with diabetes, heart disease, hypertension, hyperthyroidism, benign prostatic hypertrophy, and glaucoma. These clients should contact their primary health care provider before taking over-the-counter decongestants.
After teaching a group of nursing students about antihistamines, the instructor determines that the teaching was successful when the students identify which of the following as less sedating? Select all that apply.
- A. Loratadine (Claritin)
- B. Fexofenadine (Allegra)
- C. Cetirizine (Zyrtec)
- D. Brompheniramine (Lodrane)
- E. Clemastine (Tavist)
Correct Answer: A,B,C
Rationale: Loratadine, fexofenadine, and cetirizine are considered second-generation antihistamines that are less sedating than first-generation antihistamines (brompheniramine and clemastine).
A nurse is caring for a client with thick sputum who is having difficulty bringing up mucus. Which nursing diagnosis would the nurse most likely identify?
- A. Ineffective Airway Clearance
- B. Acute Pain
- C. Risk for Injury
- D. Impaired Oral Mucous Membranes
Correct Answer: A
Rationale: Thick sputum interferes with moving air effectively in and out of the respiratory tract. Therefore, the most likely nursing diagnosis would be Ineffective Airway Clearance. There is no evidence of pain. Risk for Injury would be appropriate if the client was experiencing sedation or drowsiness from the prescribed medication. Impaired Oral Mucous Membranes would be appropriate if the client was experiencing dry mouth from the medication.