Nokea
A nurse is teaching a client about taking antihistamines. Which of the following instructions should the nurse include in the teaching plan? Select all that apply.
- A. Operating machinery and driving may be dangerous while taking antihistamines.
- B. Committaking antihistamines even if nasal infection develops.
- C. The effect of antihistamines is not felt until a day later.
- D. Do not use alcohol with antihistamines.
- E. Increase fluid intake to 2,000 mL/day.
Correct Answer: A,D,E
Rationale: Antihistamines have an anticholinergic action and a drying effect and reduce nasal, salivary, and lacrimal gland hypersecretion (runny nose, tearing, and itching eyes). An adverse effect is drowsiness, so operating machinery and driving are not recommended. There is also an additive depressant effect when alcohol is combined with antihistamines, so alcohol should be avoided during antihistamine use. The client should ensure adequate fluid intake of at least 8 glasses per day due to the drying effect of the drug.
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The nurse is teaching a client about managing osteoarthritis pain. Which non-pharmacologic intervention should be included?
- A. Apply ice packs for 30 minutes at a time.
- B. Maintain a high-protein diet.
- C. Use a heating pad on high setting.
- D. Perform gentle range-of-motion exercises.
Correct Answer: D
Rationale: Gentle range-of-motion exercises maintain joint mobility and reduce stiffness in osteoarthritis.
Which of the following signs and symptoms would probably indicate that the client with Addison's disease is receiving too much glucocorticoid replacement?
- A. Anorexia.
- B. Dizziness.
- C. Rapid weight gain.
- D. Poor skin turgor.
Correct Answer: C
Rationale: Rapid weight gain indicates fluid retention, a sign of excessive glucocorticoid replacement.
Metoclopramide (Reglan) is ordered as a premedication for a client about to undergo a gastroduodenoscopy. The nurse expects which of the following as the primary therapeutic effect?
- A. Increased gastric pH.
- B. Increased gastric emptying.
- C. Reduced anxiety.
- D. Inhibited respiratory secretions.
Correct Answer: B
Rationale: Metoclopramide promotes gastric emptying, which is beneficial before gastroduodenoscopy to reduce the risk of aspiration and improve visualization.
A client with a spinal cord injury is at risk for autonomic dysreflexia. Which symptom should the nurse monitor for?
- A. Bradycardia.
- B. Hypotension.
- C. Excessive sweating above the injury level.
- D. Numbness in the lower extremities.
Correct Answer: C
Rationale: Excessive sweating above the injury level is a hallmark symptom of autonomic dysreflexia, a medical emergency.
A nurse is caring for a client with a central venous catheter (CVC) in place. Which action by the nurse is most effective in preventing central line-associated bloodstream infections (CLABSI)?
- A. Performing hand hygiene before and after any manipulation of the CVC.
- B. Monitoring the client's temperature every 4 hours.
- C. Administering prophylactic antibiotics.
- D. Ensuring the client maintains strict bed rest to prevent catheter movement.
Correct Answer: A
Rationale: Hand hygiene is the most effective measure to prevent CLABSI by reducing microbial contamination.