A client with allergic rhinitis is taking the over-the-counter antihistamine diphenhydramine HCL. Which instruction is most important for the nurse to provide this client?

Do not take the medication more than once every 8 hours.

Take the medication with food to prevent gastric upset.

Avoid driving, since this medication causes drowsiness.

Use sugarless candy or gum to help prevent a dry mouth.

Answer and Explanation

The Correct Answer is C

A. Do not take the medication more than once every 8 hours:
Diphenhydramine is typically dosed every 4 to 6 hours, not just once every 8 hours. However, this instruction is less critical compared to addressing the safety concerns related to drowsiness.

B. Take the medication with food to prevent gastric upset:
Diphenhydramine is generally not known to cause significant gastric upset, so this instruction is less critical. The primary concern with diphenhydramine is its sedative effects rather than gastrointestinal issues.

C. Avoid driving, since this medication causes drowsiness:
Diphenhydramine is known to cause significant drowsiness and sedation. Advising the client to avoid driving is crucial to prevent accidents and ensure their safety, making this the most important instruction.

D. Use sugarless candy or gum to help prevent a dry mouth:
While diphenhydramine can cause dry mouth, using sugarless candy or gum is a helpful but secondary instruction. The primary concern with diphenhydramine is its sedative effect, which affects the client's ability to drive safely.

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Correct Answer is D

Explanation

A. Many of the herbal preparations are helpful primarily because of their placebo effect:
While placebo effects can play a role, many herbal preparations, including echinacea, have been studied for their potential therapeutic benefits beyond placebo effects. This statement oversimplifies and may dismiss valid efficacy.

B. This product is essentially harmless but also is not very beneficial in treating skin infections:
Echinacea is generally considered safe for topical use and has been used for various infections, including canker sores. This statement underestimates the potential benefits of echinacea in treating certain conditions.

C. Topical echinacea is usually used to soothe burns and can cause damage to the skin:
Topical echinacea is commonly used for various skin conditions, but it is not typically associated with causing skin damage. The statement may create unnecessary concern.

D. Echinacea seems to be useful in the treatment of some infections, such as canker sores:
Echinacea has been used traditionally and in some studies for its antimicrobial properties, which may be beneficial for certain infections, including canker sores. This statement acknowledges its potential utility without dismissing its benefits.

A. Determine Glasgow Coma Scale score. B. Prepare to assist with chest tube insertion. C. Initiate cardiopulmonary resuscitation (CPR). D. Administer a second dose of naloxone.

Correct Answer is D

Explanation

A) Determine Glasgow Coma Scale score: While assessing the Glasgow Coma Scale (GCS) score is important for evaluating the level of consciousness and neurological status, it does not address the immediate life-threatening issue of severe respiratory depression and hypoxia. The client's critical respiratory status and low oxygen saturation require more urgent intervention.

B) Prepare to assist with chest tube insertion: Preparing for chest tube insertion is not appropriate in this scenario, as the client's symptoms are related to severe respiratory depression rather than a condition that would require chest drainage. Chest tube insertion is indicated for conditions such as pneumothorax or pleural effusion, not for opioid overdose.

C) Initiate cardiopulmonary resuscitation (CPR): CPR would be necessary if the client were in cardiac arrest or if there were no pulse and respiratory effort. However, the immediate issue appears to be severe respiratory depression rather than cardiac arrest, so administering a second dose of naloxone is a more appropriate and immediate action to address the cause of the client's condition.

D) Administer a second dose of naloxone: Given the client’s severe respiratory depression and low oxygen saturation despite the initial dose of naloxone, it is crucial to administer a second dose. Naloxone is used to reverse opioid overdose effects, and its administration should be repeated if symptoms persist, ensuring the client’s safety and potentially reversing the opioid’s effects on the respiratory system.

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A client with allergic rhinitis is taking the over-the-counter antihistamine diphenhydramine HCL. Which instruction is most important for the nurse to provide this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The home health nurse observes that a female client is using a topical preparation that contains echinacea to treat a canker sore. Her husband expresses concern regarding the effectiveness and safety of using herbs. How should the nurse respond?

Correct Answer is D

Explanation

The nurse administers naloxone to a client with opioid-induced respiratory depression. One hour later, nursing assessment reveals that the client has a respiratory rate of 4 breaths/minute, oxygen saturation of 75%, and is unable to be aroused. Which action should the nurse implement?

Correct Answer is D

Explanation

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