Nokea
Your client has a doctor's order for the antihistamine medication diphenhydramine for sleep. What should you do?
- A. Question the order because Benadryl is an antihistamine and not a sleeping medication.
- B. Refuse to give the Benadryl because this medication is a stimulant.
- C. Question the order because Benadryl is contraindicated when the client has a sleep inducement disorder.
- D. Give the Benadryl because sleep inducement is an accepted off label use of this medication.
Correct Answer: D
Rationale: Diphenhydramine (Benadryl) is commonly used off-label for sleep due to its sedative properties, making it appropriate if ordered for this purpose.
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The nurse is caring for a client with a history of chronic obstructive pulmonary disease who is prescribed salmeterol (Serevent). The nurse should instruct the client to:
- A. Use the inhaler as needed for shortness of breath.
- B. Rinse the mouth after using the inhaler.
- C. Shake the inhaler before use.
- D. Use the inhaler twice daily.
Correct Answer: D
Rationale: Salmeterol is a long-acting bronchodilator used twice daily for maintenance therapy in COPD.
The nurse is instructing an unlicensed assistive personnel on the prevention of postoperative pulmonary complications. Which of the following statements indicates that the assistant has understood the nurse's instructions?
- A. I will turn the client every 4 hours.'
- B. I will keep the client's head elevated.'
- C. I should suction the client every 2 hours.'
- D. I will have the client take 5 to 10 deep breaths every hour.'
Correct Answer: D
Rationale: Deep breathing exercises hourly prevent atelectasis and promote lung expansion, key to preventing pulmonary complications.
Betamethasone (Celestone) syrup 0.9 mg has been ordered. It is available in a 0.6 mg/5 mL solution. How many milliliters should the nurse administer?
- A. 5 mL
- B. 7.5 mL
- C. 10 mL
- D. 2.5 mL
Correct Answer: B
Rationale: To calculate: (0.9 mg / 0.6 mg) × 5 mL = 7.5 mL.
The nurse is assessing an infant diagnosed with bacterial meningitis. The nurse should ask the parent if the infant has which of the following? Select all that apply.
- A. Fever.
- B. Vomiting.
- C. Diarrhea.
- D. Poor feeding.
- E. Abdominal pain.
Correct Answer: A,B,D
Rationale: Bacterial meningitis in infants commonly presents with fever, vomiting, and poor feeding. Diarrhea and abdominal pain are less typical symptoms in this age group.
The nurse assesses the environmental safety of a client receiving home oxygen therapy. Which observation by the nurse indicates that the client needs further teaching to ensure safety?
- A. Oxygen used 30 feet from a gas stove
- B. Oxygen tank stored in the tank holder
- C. No smoking' sign posted at the front door
- D. Oxygen concentrator propped against a wall
Correct Answer: D
Rationale: The oxygen concentrator should be free and clear of walls or other enclosed spaces to allow adequate air circulation around the unit; otherwise, the unit can overheat and increase the risk of fire. Clients should avoid using oxygen within 10 feet of open flames because oxygen fuels a fire. Oxygen tanks are secured in a holder to stabilize and protect the tank, and a 'no smoking' sign should be in view to alert visitors about the risk.