Nokea
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.
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The nurse understands that codeine-containing antitussives should be used cautiously in clients with which of the following conditions? Select all that apply.
- A. Pregnancy
- B. Convulsive disorders
- C. Prostatic hypertrophy
- D. Hyperlipidemia
- E. Type 2 diabetes
Correct Answer: A,B,C
Rationale: Codeine-containing antitussives should be used cautiously during pregnancy and labor and in clients with COPD, acute asthma attacks, pre-existing respiratory disorders, acute abdominal conditions, head injury, increased intracranial pressure, convulsive disorders, hepatic or renal impairment, and prostatic hypertrophy.
A nurse is assigned to care for a client with a nonproductive cough. The client has been prescribed codeine sulfate. The nurse understands that this drug is contraindicated in which client?
- A. Client with head injury
- B. Client with COPD
- C. Premature infant
- D. Clients with asthma
Correct Answer: C
Rationale: Codeine sulfate is contraindicated in premature infants. Codeine sulfate should be used cautiously in clients with head injury, COPD, and asthma.
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.
A client is prescribed an antitussive for home use. Which of the following should a nurse include in the client's teaching plan? Select all that apply.
- A. Decreasing fluid intake during treatment with an antitussive
- B. Encouraging the use of sedatives during treatment
- C. Drinking fluids at least 30 minutes after taking a lozenge form
- D. Swallowing oral antitussive capsules whole
- E. Avoiding respiratory irritants during antitussive treatment
Correct Answer: D,E
Rationale: A client's antitussive teaching plan should include the following instructions, do not exceed recommended dose; avoid respiratory irritants; drink plenty of fluids if not contraindicated; swallow oral capsules whole; avoid drinking fluids for 30 minutes after taking a lozenge; do not use alcohol or other CNS depressants while being treated with antitussives; and contact the physician if cough is not relieved or becomes worse or is accompanied by chills, fever, chest pain, or sputum production.
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.