A nurse is teaching a client who has a new prescription for diphenhydramine for allergic rhinitis. The nurse should instruct the client to monitor for which of the following manifestations as an adverse effect of this medication? (Select all that apply.)

A. Assessing changes in body temperature. The RN is responsible for assessing trends in temperature and identifying potential clinical implications (e.g., infection, sepsis, or medication reactions).

B. Being aware of the usual values for the patient. While knowing baseline values is important, this is not solely an RN responsibility. Nursing assistants and other healthcare providers also note baseline values.

C. Obtaining temperature measurements at ordered frequency. This task can be delegated to a nursing assistant or licensed practical nurse (LPN), as it is a routine task that does not require assessment.

D. Using an appropriate route and device. While the RN ensures correct procedures are followed, this specific task can also be performed by trained assistive personnel. The RN focuses on interpretation and intervention.

A. Pressure points: Pressure points (e.g., sacrum, heels, elbows, shoulders, hips) are at the highest risk for breakdown, ulcers, and impaired circulation. This makes them the priority assessment for skin integrity.

B. Pulse points: While checking pulses is important for circulatory assessment, it is not directly related to skin integrity assessment.

C. Breath sounds: Breath sounds assess respiratory function and are not a direct indicator of skin integrity.

D. Bowel sounds: Bowel sounds assess gastrointestinal function and are not relevant in a skin integrity assessment.