Nokea
A client suffers from motion sickness. Which of the following would the nurse anticipate the primary health care provider to prescribe? Select all that apply.
- A. Promethazine (Phenergan)
- B. Diphenhydramine (Benadryl)
- C. Levocetirizine (Xyzal)
- D. Azelastine (Astelin)
- E. Pseudoephedrine (Sudafed)
Correct Answer: A,B
Rationale: Both promethazine and diphenhydramine can be used in the treatment of motion sickness. None of the other drugs listed would be appropriate.
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A nurse is assigned to care for a client with bronchial irritation. The client is prescribed diphenhydramine. Before administering the drug, which of the following would the nurse do?
- A. Document color and amount of any sputum present.
- B. Record the previous prescriptions.
- C. Take vital signs every 4 hours.
- D. Assess the client's cardiovascular status.
Correct Answer: A
Rationale: Before drug administration, the nurse should document the color and amount of any sputum present. The nurse need not record the previous prescriptions; however, the nurse should determine if any drugs the client uses would potentially interact with diphenhydramine. The nurse needs to take the client's vital signs, but not every 4 hours. The nurse needs to assess the respiratory status of the client before administering mucolytics and expectorants, but not before administering diphenhydramine HCl. Assessing the client's cardiovascular status is not necessary.
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.
When teaching a client about using a decongestant in a nasal spray form, which instruction would the nurse include? Select all that apply.
- A. Recline on a bed and hang your head over the edge.
- B. Sniff hard for a few minutes after administration.
- C. Make sure the tip of the container is touching the nasal mucosa.
- D. Do not share the container with anyone except family members.
- E. Know that nasal burning or stinging may occur.
Correct Answer: B,E
Rationale: A client should be instructed to administer a nasal spray while sitting upright not allow the tip of the container to touch the nasal mucosa, and to sniff hard for a few minutes after administration. The client may experience some burning or stinging after the administration of the nasal spray. The container should not be shared with anyone.
A client with allergic rhinitis is prescribed an antihistamine. The nurse instructs the client to suck on sugarless hard candy to address which of the following?
- A. Drowsiness and sedation
- B. Threkening of the bronchial secretions
- C. Altered sensation of taste
- D. Dryness of the oral mucosa and the throat
Correct Answer: D
Rationale: The nurse should instruct the client to suck on a sugarless hard candy to prevent dryness of the oral mucosa and the throat, which is a side effect of antihistamine therapy. Sucking on candy does not relieve drowsiness, sedation, and thickening of the bronchial mucosa seen with antihistamine therapy. Altered sense of taste does not occur with most antihistamines.
Eucalyptus is an herbal product that can be used as a decongestant and expectorant. In which of the following client populations would the nurse identify a contraindication for its use? Select all that apply.
- A. Pregnant females
- B. Children younger than 2 years of age
- C. Lactating females
- D. Postmenopausal females
- E. Men
Correct Answer: A,B,C
Rationale: The use of eucalyptus is contraindicated during pregnancy and lactation, as well as in people who are hypersensitive to eucalyptus and in children younger than 2 years of age.