Nokea
After teaching a client about his upper respiratory drug therapy, the nurse determines that additional teaching is needed when the client identifies which of the following as a reason to notify his primary health care provider?
- A. Cough changes from nonproductive to productive.
- B. Sputum appears clear.
- C. Sputum increases.
- D. Shortness of breath occurs.
Correct Answer: B
Rationale: The client should notify his primary health care provider if the type of cough changes, sputum changes color or increases, and shortness of breath occurs. Clear sputum is normal.
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A client has a nursing diagnosis of Ineffective Airway Clearance. Which of the following would the nurse include in the client's plan of care? Select all that apply.
- A. Encouraging increased fluid intake
- B. Assisting the client in taking deep, diaphragmatic breaths
- C. Discouraging client movement
- D. Instructing the client to avoid coughing
- E. Encouraging the client to change positions
Correct Answer: A,B,E
Rationale: Clients should be encouraged to change positions frequently, breathe deeply, and increase fluid intake to aid in effectively clearing the airway of sputum. Coughing helps to move mucus.
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.
Assessment of a client reveals that he is taking phenelzine (Nardil), a monoamine oxidase inhibitor, for depression. The client reports that he just started using dextromethorphan over the counter without consulting his primary health care provider. The nurse would be alert for which of the following? Select all that apply.
- A. Hypertension
- B. Fever
- C. Coma
- D. Constipation
- E. Shortness of breath
Correct Answer: B,C
Rationale: Coadministration of dextromethorphan and a monoamine oxidase inhibitor may result in hypotension, fever, nausea, leg jerking, and coma.
A client has been prescribed a nasal decongestant for nasal stuffiness due to a common cold. The client is also taking an antidepressant that is a monoamine oxidase inhibitor. The nurse would warn the client about which of the following.
- A. Hypotension
- B. Severe headache
- C. Sedation
- D. Bradycardia
Correct Answer: B
Rationale: The nurse should warn the client of the possibility of severe headache due to an interaction between the two drugs. Such an interaction may also result in hypertensive crisis instead of hypotension. Sedation and bradycardia do not occur when an MAOI and decongestant are used together.
A client with vasomotor rhinitis has been prescribed an antihistamine. The client is eager to know whether the prescribed antihistamine may cause excessive sedation. Which antihistamine would the nurse identify as having very little sedative effect?
- A. Brompheniramine
- B. Clemastine
- C. Chlorpheniramine
- D. Azelastine
Correct Answer: D
Rationale: The nurse should assure the client that azelastine has very little sedative effect; it is a second-generation antihistamine with little effect on central nervous system (CNS) depression. Brompheniramine, clemastine, and chlorpheniramine are first-generation antihistamines. Sedation is seen more often with first-generation antihistamines.