While obtaining a health history, the nurse learns that the client is allergic to bee stings. When obtaining the client’s medication history, the nurse should determine if the client keeps which medication on hand?
- A. Diphenhydramine hydrochloride (Benadryl)
- B. Guaifenesin (Robitussin)
- C. Pseudoephedrine hydrochloride (Sudafed)
- D. Loperamide (Imodium)
Correct Answer: A
Rationale: Rationale:
A: Diphenhydramine hydrochloride (Benadryl) is an antihistamine commonly used to treat allergic reactions, including those from bee stings. It can help alleviate symptoms like itching and swelling. Keeping Benadryl on hand is crucial for managing an allergic reaction promptly.
Other Choices:
B: Guaifenesin (Robitussin) is an expectorant used to treat coughs, not allergic reactions.
C: Pseudoephedrine hydrochloride (Sudafed) is a decongestant used for nasal congestion, not allergic reactions.
D: Loperamide (Imodium) is an antidiarrheal used to treat diarrhea, not allergic reactions.
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Which of the following would the nurse use to document a finding that the patient’s ear is draining?
- A. Otorrhea
- B. Otalgia
- C. Ototoxic
- D. Tinnitus
Correct Answer: A
Rationale: The correct answer is A: Otorrhea. Otorrhea refers to the discharge of fluid from the ear, indicating an abnormal finding of ear drainage. This term specifically describes the symptom of ear drainage, making it the most appropriate choice for documenting this finding. Otalgia (choice B) refers to ear pain, ototoxic (choice C) refers to substances that are harmful to the ear, and tinnitus (choice D) refers to ringing in the ears, none of which accurately describe ear drainage. Therefore, the correct choice is A as it specifically addresses the symptom of ear drainage.
Mrs. Diwa has been diagnosed with systemic lupus erythematosus, the nurse upon assessment can expect to find which of the following?
- A. dysphagia
- B. dryness or itching of genitalia
- C. decreased visual acuity or blindness
- D. abnormal lung sounds
Correct Answer: D
Rationale: The correct answer is D because systemic lupus erythematosus can lead to inflammation in the lungs, causing abnormal lung sounds. Dysphagia (choice A) is not typically associated with lupus. Dryness or itching of genitalia (choice B) is more characteristic of conditions like yeast infections or dermatitis. Decreased visual acuity or blindness (choice C) is not a common manifestation of lupus. Abnormal lung sounds (choice D) are commonly seen in lupus patients due to inflammation and possible lung involvement.
A nurse approaches a hospitalized poststroke patient from the patient’s left side to do an assessment. The patient is staring straight ahead, and does not respond to the nurse’s presence or voice. Which action should the nurse take first?
- A. Walk to the other side of the bed and try again
- B. Speak more loudly and clearly
- C. Wave his or her fingers in front of the patient’s face
- D. Use a picture to explain to the patient what the nurse is going to do.
Correct Answer: A
Rationale: Rationale:
1. By approaching the patient from the other side, the nurse can assess if the patient has a visual field deficit.
2. This step helps determine if the lack of response is due to a sensory issue.
3. It allows the nurse to rule out unilateral neglect or hemianopsia.
4. Walking to the other side is a basic assessment technique to evaluate visual and sensory deficits in poststroke patients.
Other Choices:
B. Speaking more loudly and clearly may not address the potential sensory issues the patient is experiencing.
C. Waving fingers in front of the patient's face does not provide a comprehensive assessment of visual field deficits.
D. Using a picture may be helpful, but addressing the potential visual field deficit should be prioritized first.
The client is taking phenyton (Dilantin) for seizure control. A sample is drawn to determine the serum drug level, and the nurse reviews the results. Which of the following would indicate a therapeutic serum drug range?
- A. 5 to 10 mcg/ml.
- B. 20 to 30 mcg/ml.
- C. 10 to 20 mcg/ml.
- D. 30 to 40 mcg/ml.
Correct Answer: A
Rationale: The correct answer is A (5 to 10 mcg/ml) because this range is typically considered therapeutic for phenytoin (Dilantin) for seizure control. Levels below 5 mcg/ml may be subtherapeutic, leading to inadequate seizure control. Levels above 10 mcg/ml can increase the risk of toxicity. Choices B, C, and D are incorrect because they are outside the optimal therapeutic range, leading to either ineffective treatment (B, C) or an increased risk of adverse effects (D). Monitoring drug levels helps ensure the medication's effectiveness while minimizing side effects.
A client agreed to become an organ donor is pronounced dead. What is the most important factor in selecting a transplant recipient?
- A. Blood relationship
- B. Compatible blood and tissue types
- C. Sex and size
- D. Need
Correct Answer: B
Rationale: The correct answer is B: Compatible blood and tissue types. This is crucial to minimize the risk of rejection and ensure a successful transplant. Matching blood and tissue types help prevent the recipient's immune system from attacking the new organ. Blood relationship (A) is not as important as compatibility. Sex and size (C) are important considerations for certain transplants but not the most crucial factor. Need (D) is relevant but does not outweigh the importance of compatibility to ensure a successful transplant.