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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.
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A client is suffering from rebound congestion. Which of the following would the nurse expect to do to help the client experience relief from rebound congestion? Select all that apply.
- A. Suggest the client switch from a topical decongestant to an oral product.
- B. Recommend the client switch from an oral decongestant to a topical product.
- C. Tell the client to abruptly discontinue the decongestant product.
- D. Advise the client to gradually discontinue the decongestant product.
- E. Suggest a saline irrigation of the nasal passages in place of the decongestant.
Correct Answer: A,D,E
Rationale: Rebound congestion can be treated by a switch from a topical to an oral decongestant, gradual discontinuation of the topical decongestant, or replacement of the topical decongestant with saline irrigation of the nasal passages.
The nurse is preparing to administer a drug that acts by reducing the swelling in the nasal passages by vasoconstriction. Which of the following might the nurse be administering? Select all that apply.
- A. Loratadine
- B. Guaifenesin
- C. Dextromethorphan
- D. Phenylephrine
- E. Oxymetazoline
Correct Answer: D,E
Rationale: Phenylephrine and oxymetazoline are decongestants that reduce swelling in the nasal passages by vasoconstriction. Loratadine is an antihistamine, guaifenesin is an expectorant, and dextromethorphan is a centrally acting antitussive.
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 client has been prescribed a decongestant drug for congestion associated with rhinitis. When teaching the client about this drug, which of the following would the nurse include as a possible adverse reaction?
- A. Decreased pulse rate
- B. Blurred vision
- C. Drowsiness
- D. Dryness of throat
Correct Answer: B
Rationale: The nurse should inform the client that blurred vision is a possible adverse reaction of decongestant drugs. Additionally, an increased and not decreased pulse rate may also be seen. Drowsiness is not seen with decongestant usage. Dryness of the nasal mucosa and not the throat may be seen with decongestant drugs, which are used mostly as topical sprays and drops.
A nursing instructor is describing the advantages of using a second-generation antihistamine over a first-generation antihistamine. Which of the following would the instructor most likely include? Select all that apply.
- A. Less sedation
- B. Fewer anticholinergic effects
- C. Less nausea
- D. Can be used during pregnancy
- E. Can be used during lactation
Correct Answer: A,B
Rationale: Second-generation antihistamines cause less sedation and fewer anticholinergic effects because they selectively bind to peripheral rather than central H1 receptors. Some first-generation antihistamines can be used as antiemetics. Use of any antihistamine is contraindicated during pregnancy and lactation.