Nokea
Chlorhexidine gluconate is being used in a client for preoperative skin preparation. Which of the following if noted would alert the nurse to a possible adverse reaction?
- A. Taste perversion
- B. Headache
- C. Deafness
- D. Mild erythema
Correct Answer: C
Rationale: The nurse should monitor for deafness as an adverse reaction to the use of chlorhexidine gluconate. Taste perversion, headache, and mild erythema are adverse reactions to penciclovir.
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The nurse might suspect a hypersensitivity reaction has occurred in a client using azelaic acid (Azelex) if the client experiences a combination of which of the following? Select all that apply.
- A. Pruritus
- B. Urticaria
- C. Vomiting
- D. Erythema
- E. Mental status changes
Correct Answer: A,B,D
Rationale: Topical anti-infectives, like azelaic acid (Azelex), result in a rash, pruritus, urticaria, dermatitis, irritation, and erythema, which may indicate a hypersensitivity reaction to the drug.
Which of the following would be most important to include in the preadministration assessment of a client who is receiving topical therapy for a skin disorder? Select all that apply.
- A. Size of the area affected
- B. Appearance of the lesions
- C. Report of pain or burning
- D. Client's weight
- E. Blood pressure
Correct Answer: A,B,C
Rationale: The preadministration assessment involves a visual inspection and palpation of the involved area(s). The areas of involvement, including the size, color, and appearance, are carefully measured and documented. The appearance of the skin lesions and reports of pain or burning are noted to establish an accurate baseline for treatment.
A nurse is instructing a client about how to apply the topical medication prescribed. Which of the following would the nurse identify as an appropriate way to remove the drug from the container? Select all that apply.
- A. Finger cot
- B. Clean finger
- C. Tongue blade
- D. Gauze pad
- E. Cotton swab
Correct Answer: A,C,D,E
Rationale: Using a finger cot, tongue blade, gauze pad, or cotton swab ensures hygienic application of the topical medication, minimizing contamination and direct skin contact.
A client is prescribed topical betamethasone. Which of the following would the nurse include when explaining the possible adverse reactions that may occur? Select all that apply.
- A. Burning
- B. Dryness
- C. Pruritus
- D. Nausea
- E. Fever
Correct Answer: A,B,C
Rationale: Localized reactions caused by the topical administration of betamethasone that the nurse should discuss with the client include burning, pruritus, irritation, redness, dryness, allergic contact dermatitis, and secondary infection.
A client is to receive topical masoprocol. The nurse alerts the client to the possibility of which of the following as an adverse reaction? Select all that apply.
- A. Mild pain
- B. Scaling
- C. Numbness
- D. Flu-like syndrome
- E. Dry skin
Correct Answer: B,D,E
Rationale: Adverse reactions related to the topical administration of masoprocol (Actinex) include transient burning sensation, rash, dry skin, scaling, and flu-like syndrome.