The practical nurse (PN) is caring for a client who has a prescription for loratadine by mouth daily as needed. Which sign indicates to the PN that there is a need to administer the medication?
Ulceration on the corner of the upper lip.
Ecchymosis and petechiae on the legs
Red welts widespread over the chest.
Red papules and pustules on the face.
The Correct Answer is C
The correct answer is choice C. Red welts widespread over the chest.
Choice A rationale:
Ulceration on the corner of the upper lip does not indicate a need for loratadine administration. Loratadine is an antihistamine commonly used to relieve symptoms of allergies such as sneezing, runny nose, and itchy or watery eyes. Ulceration on the lip is not associated with an allergic reaction.
Choice B rationale:
Ecchymosis and petechiae on the legs are not related to the need for loratadine. These findings suggest potential bleeding or clotting disorders, and loratadine does not address such issues.
Choice C rationale:
Red welts widespread over the chest are indicative of hives (urticaria), which are often caused by allergic reactions. Loratadine can help alleviate the symptoms of hives by blocking histamine release, making it an appropriate choice for this condition.
Choice D rationale:
Red papules and pustules on the face are unlikely to be treated with loratadine. These skin manifestations may be related to various dermatological conditions, but not necessarily allergic reactions that loratadine is primarily used to manage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is the most important follow-up assessment for the PN to implement because it can detect signs of bleeding, infection, or shock that may result from the unsecured surgical dressing. The PN should monitor the client's blood pressure, pulse, temperature, and respiratory rate and report any abnormal changes.
B. Fluid volume intake and output is not the most important follow-up assessment for this client and may not reflect the current status of the client's fluid balance or blood loss.
C. Volume of peripheral pulses is not the most important follow-up assessment for this client and may not be affected by the unsecured surgical dressing unless it is located on a limb or near a major artery.
D. Incisional pain scale rating is not the most important follow-up assessment for this client and may not indicate the severity or cause of the client's pain.
Correct Answer is B
Explanation
Choice A rationale:
The risk of infection is not the priority nursing problem in this scenario. While the darkened membranes and smoky breath may be indicative of potential infection, addressing ineffective airway clearance is more urgent as it directly impacts the client's breathing and oxygenation.
Choice B rationale:
Ineffective airway clearance should be the priority nursing problem. Darkened membranes of the mouth and smoky breath suggest possible inhalation injury or airway obstruction.
Maintaining a patent airway is crucial for adequate oxygenation and to prevent further complications.
Choice C rationale:
Acute pain is not the priority nursing problem in this case. Although it is essential to address any discomfort the client may be experiencing, it takes a back seat to the more critical issue of ineffective airway clearance.
Choice D rationale:
Disturbed body image is not the priority nursing problem when the client has darkened mouth membranes and smoky breath. While it is important to address body image concerns, the immediate focus should be on managing and improving the client's airway clearance.
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