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A nurse is collecting data from a client who received diphenhydramine 1 hr ago after developing an allergic reaction to trimethoprim-sulfamethoxazole. Which of the following statements by the client should indicate to the nurse that the medication is effective?
- A. My appetite is increased.'
- B. I don't have a headache anymore.'
- C. My voice is no longer hoarse.'
- D. I am feeling more alert.'
Correct Answer: C
Rationale: The correct answer is C: "My voice is no longer hoarse." This statement indicates the effectiveness of diphenhydramine, an antihistamine used to treat allergic reactions. Hoarseness is a common symptom of allergic reactions, so if the client's voice is no longer hoarse, it suggests that the medication has alleviated the allergic response.
A: Increased appetite is not a direct indicator of the effectiveness of diphenhydramine in treating an allergic reaction.
B: Relief from headaches is not a specific symptom related to allergic reactions or a typical indicator of diphenhydramine effectiveness.
D: Feeling more alert is not a direct indicator of the effectiveness of diphenhydramine in treating allergic reactions.
Therefore, option C is the most appropriate choice as it directly relates to the specific symptom of the allergic reaction that diphenhydramine is intended to treat.
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A nurse in a provider's office is collecting data from a client who continues to have a migraine headache after taking sumatriptan orally 2 hr ago. Which of the following findings is the priority for the nurse to report?
- A. Tingling sensation
- B. Hypertension
- C. Dizziness
- D. Flushing
Correct Answer: B
Rationale: The correct answer is B: Hypertension. This is the priority finding for the nurse to report because sumatriptan, a medication used for migraines, can potentially cause a rare but serious side effect of increased blood pressure. Hypertension can lead to severe complications such as stroke or heart attack. Reporting hypertension promptly allows for timely intervention to prevent harm.
Other choices are less urgent:
A: Tingling sensation is a common side effect of sumatriptan and usually resolves on its own.
C: Dizziness may occur with sumatriptan but is not as concerning as hypertension.
D: Flushing is a common side effect and does not require immediate action like hypertension.
A nurse is collecting data from a client who is taking dimenhydrinate to treat motion sickness. Which of the following findings is an adverse effect of this medication?
- A. Drowsiness
- B. Hypertension
- C. Polyuria
- D. Dependent edema
Correct Answer: A
Rationale: The correct answer is A: Drowsiness. Dimenhydrinate is an antihistamine commonly used for motion sickness, which can cause drowsiness as a common adverse effect due to its sedative properties. This is because it can cross the blood-brain barrier and affect the central nervous system, leading to drowsiness. The other options are incorrect because hypertension (B) is not a known adverse effect of dimenhydrinate, polyuria (C) is excessive urination, which is not typically associated with this medication, and dependent edema (D) is swelling due to fluid buildup, which is also not commonly caused by dimenhydrinate. Therefore, the correct adverse effect to expect with dimenhydrinate use is drowsiness.
A nurse is reviewing a list of current medications for a client who is starting therapy with furosemide. Which of the following medications should the nurse identify as being contraindicated?
- A. Levothyroxine
- B. Cetirizine
- C. Lithium carbonate
- D. Albuterol
Correct Answer: C
Rationale: The correct answer is C: Lithium carbonate. Furosemide can decrease lithium excretion, leading to increased lithium levels and toxicity. Levothyroxine (A), Cetirizine (B), and Albuterol (D) do not have significant interactions with furosemide. In summary, the other choices are incorrect because they do not pose a contraindication when taken concurrently with furosemide, unlike lithium carbonate.
A nurse is reinforcing teaching with a client who has angina and a new prescription of nitroglycerin sublingual. Which of the following statements by the client indicates an understanding of the teaching?
- A. If my pain is not relieved in 20 minutes, I will take a second tablet.'
- B. I will keep my tablets on a shelf in the bathroom.'
- C. I should be sure to swallow the tablet whole.'
- D. If my mouth is dry, I will take a sip of water before I take the tablet.'
Correct Answer: D
Rationale: The correct answer is D: "If my mouth is dry, I will take a sip of water before I take the tablet." This statement indicates an understanding of how to properly administer nitroglycerin sublingual. Taking the medication under the tongue allows for faster absorption. Taking a sip of water before taking the tablet helps moisten the mouth and aids in the absorption of the medication. This step is crucial for the effectiveness of nitroglycerin in relieving angina symptoms.
Other choices are incorrect:
A: Taking a second tablet before the 20-minute mark is not recommended as it can lead to an overdose.
B: Keeping tablets in the bathroom exposes them to moisture, affecting their potency.
C: Nitroglycerin sublingual should not be swallowed but dissolved under the tongue for rapid absorption.
A nurse is reinforcing teaching with a client who has COPD and has been taking long-term high doses of prednisone. Which of the following instructions should the nurse include in the teaching?
- A. Limit potassium-containing foods in your diet.'
- B. Withhold prednisone for 48 hours prior to receiving contrast dye.'
- C. Measure your blood glucose levels periodically.'
- D. Take prednisone on an empty stomach.'
Correct Answer: C
Rationale: The correct answer is C: Measure your blood glucose levels periodically. Clients taking long-term high doses of prednisone are at risk for developing steroid-induced diabetes due to the drug's effect on blood glucose levels. Monitoring blood glucose levels will help detect any abnormalities early, allowing for timely intervention.
A: Limiting potassium-containing foods is not directly related to prednisone use in COPD.
B: Withholding prednisone for 48 hours prior to receiving contrast dye can lead to adrenal insufficiency in clients on long-term prednisone therapy.
D: Taking prednisone on an empty stomach is not a specific instruction related to managing COPD or prednisone therapy.