Four hours after administering promethazine to a male patient, the practical nurse (PN) takes his temperature.
When the patient asks the PN about the reason for taking his temperature, how should the PN respond?
Encourage the patient to share his concerns about the care plan.
Explain the need to assess for medication side effects.
Assure that vital signs are routinely taken every four hours.
Describe how the medication works to lower body temperature.
None
None
The Correct Answer is B
Choice A rationale
Encouraging the patient to share his concerns about the care plan is important, but it does not directly address the patient’s question about why his temperature is being taken.
Choice B rationale
Promethazine is a medication that can cause a variety of side effects, including changes in body temperature. Therefore, monitoring the patient’s temperature can help assess for potential side effects of the medication. This is the most direct and relevant response to the patient’s question.
Choice C rationale
While it’s true that vital signs are often taken routinely, this does not specifically address why the patient’s temperature is being taken in this particular instance, four hours after
administering promethazine.
Choice D rationale
While promethazine can affect body temperature, it is not primarily used to lower body
temperature. Therefore, explaining that the medication works to lower body temperature may not be entirely accurate or relevant in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C.
Choice A rationale:
Wearing protective clothing when in direct sunlight is not specifically related to taking alendronate. This advice is more relevant for medications that increase photosensitivity, which is not a known side effect of alendronate.
Choice B rationale:
Sucking on hard candy to increase oral secretions is not necessary for patients taking alendronate. This advice is typically given to patients experiencing dry mouth, which is not a common side effect of alendronate.
Choice C rationale:
Drinking 8 ounces (240 mL) of water with each dose of alendronate is crucial. This helps ensure the medication reaches the stomach quickly and reduces the risk of esophageal irritation or ulcers.
Choice D rationale:
Laying supine for 30 minutes after taking alendronate is incorrect. Patients should remain upright (sitting or standing) for at least 30 minutes after taking the medication to prevent esophageal irritation and ensure the medication reaches the stomach properly.
Correct Answer is A
Explanation
Choice A rationale
If a child undergoing a blood transfusion complains of itchy skin and appears flushed, these
could be signs of a transfusion reaction. The PN should stop the transfusion immediately.
Choice B rationale
While inspecting the infusion site is a part of regular monitoring during a transfusion, it would
not typically be the first action in response to symptoms of a possible transfusion reaction.
Choice C rationale
Applying lotion to the skin would not address the underlying issue if the child is experiencing a
transfusion reaction.
Choice D rationale
Checking the vital signs is important, but the first action should be to stop the transfusion if a
reaction is suspected.
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