Which nursing intervention is most critical when administering antihistamines to a client with viral upper respiratory infection?
Advise combining antihistamines with decongestants for enhanced efficacy.
Monitor blood pressure regularly to prevent rebound hypertension.
Limit the client's fluid intake to reduce mucus production.
Educate about potential drowsiness and caution against driving.
The Correct Answer is D
A. Advise combining antihistamines with decongestants for enhanced efficacy: While these are often paired, the combination can increase the risk of side effects like tachycardia or insomnia. The nurse should not advise on combinations without a specific provider order. This does not address the most critical safety concern regarding antihistamine use.
B. Monitor blood pressure regularly to prevent rebound hypertension: Rebound hypertension is more commonly associated with the overuse of topical nasal decongestants, not systemic antihistamines. While monitoring vitals is good practice, it is not the primary safety priority for this drug class. Antihistamines are more likely to cause sedation than significant hypertensive crises.
C. Limit the client's fluid intake to reduce mucus production: Restricting fluids is contraindicated as it can lead to thickening of secretions, making them harder to expectorate. Adequate hydration is actually encouraged to help thin mucus during a respiratory infection. This advice would be scientifically unsound and potentially harmful to the patient.
D. Educate about potential drowsiness and caution against driving: First-generation antihistamines readily cross the blood-brain barrier and antagonize H1 receptors in the central nervous system. This causes significant impairment of motor skills and cognitive function, creating a major safety risk. Patient education on injury prevention is the most critical nursing intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. 30 gtt/min:This rate would deliver approximately 180 mL per hour, meaning the 500 mL would be finished in less than 3 hours. This is much faster than the 8-hour duration prescribed by the physician. Rapid infusion of saline can lead to fluid overload, especially in patients with cardiac or renal issues.
B. 15 gtt/min:At this drip rate, the patient would receive only about 45 mL per hour, totaling 360 mL over 8 hours. This results in an under-infusion that fails to meet the patient's prescribed fluid requirements. It would take over 11 hours to finish the 500 mL bag at this speed.
C. 35 gtt/min:This setting would deliver 105 mL per hour, resulting in the total volume being infused in under 5 hours. This significantly deviates from the 8-hour order and increases the risk of complications associated with rapid fluid administration. It represents a calculation error in the drip rate formula.
D. 21 gtt/min:Using the formula (500 mL multiplied by 20 gtt/mL) divided by 480 minutes, the result is 20.83. Rounding to the nearest whole number gives 21 drops per minute. This precisely ensures that the 500 mL of normal saline is delivered over the intended 8-hour period.
Correct Answer is D
Explanation
A. Decreased chest expansion during inhalation:This finding is more indicative of musculoskeletal stiffness, pain, or restrictive lung disease rather than a failure of the mucociliary escalator. While it affects ventilation, it does not directly reflect the status of the cilia or mucus transport. It is a measure of thoracic compliance.
B. Inspiratory wheezing:Wheezing indicates airway narrowing, which can be caused by various factors including bronchospasm or inflammation. While mucus can narrow the airway, wheezing is not the most specific indicator of impaired ciliary function. It is a sign of obstruction rather than a specific failure of clearance.
C. Clubbing of fingers:Clubbing is a sign of chronic systemic hypoxemia and is common in long-standing conditions like bronchiectasis or lung cancer. It reflects the duration of the disease rather than the acute functional status of the mucociliary system. It is a late-stage physical finding of chronic respiratory distress.
D. Chronic cough with sputum production:The mucociliary escalator is responsible for moving trapped particles and mucus up and out of the lungs. When this system fails, secretions accumulate in the airways, necessitating a cough to clear the debris. A productive cough is the clinical consequence of ineffective ciliary transport.
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