A nurse is collecting data from a client who received diphenhydramine 1 hr ago after developing an allergic reaction to trimethoprim-sulfamethoxazole.
Which of the following statements by the client should indicate to the nurse that the medication is effective?

"My voice is no longer hoarse.”

"I am feeling more alert.”

"I don't have a headache anymore.”

"My appetite is increased.”

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Hoarseness of voice can be a symptom of an allergic reaction, indicating swelling and inflammation in the throat. If the client’s voice is no longer hoarse after taking diphenhydramine, it suggests that the medication has been effective in reducing this symptom.

Choice B rationale:

Diphenhydramine is an antihistamine and can often cause drowsiness as a side effect. Therefore, feeling more alert would not typically indicate that the medication has been effective.

Choice C rationale:

While headaches can sometimes be associated with allergic reactions, they are not a primary symptom that diphenhydramine targets. Therefore, absence of a headache does not necessarily indicate effectiveness of the medication.

Choice D rationale:

Increased appetite is not typically associated with the effectiveness of diphenhydramine in treating allergic reactions.

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Correct Answer is C

Explanation

Choice A rationale:

Pinching the tube while connecting the syringe to it could potentially damage the tube and does not aid in medication administration.

Choice B rationale:

Elevating the head of the client’s bed to only 10° may increase the risk of aspiration. The head of the bed should be elevated to at least 30° during medication administration and for at least an hour afterward.

Choice C rationale:

Flushing the tube with normal saline following medication administration helps ensure that all medication has been administered and helps maintain tube patency.

Choice D rationale:

Combining crushed medications together in a single syringe can lead to drug interactions and can also increase the risk of tube clogging. Each medication should be administered separately.

A. "Using morphine PCA increases the client's risk of toxicity.” B. "Diarrhea is an adverse effect of morphine PCA.” C. "Check the client's pain level every 8 hours.” D. "Instruct the client's visitors not to operate the PCA pump.”

Correct Answer is D

Explanation

Choice Arationale:

Using PCA does not necessarily increase the client’s risk of toxicity. PCA allows the client to self-administer preset doses of pain medication, which can lead to better pain control with less risk of overdose.

Choice B rationale:

Diarrhea is not a common adverse effect of morphine. Constipation, not diarrhea, is a common side effect due to slowed gastrointestinal motility.

Choice Crationale:

Checking the client’s pain level every 8 hours is not sufficient when using PCA. Pain levels should be assessed more frequently, ideally before and after each administration of the medication. This allows for timely adjustments to the medication regimen if needed.

Choice D rationale:

Instructing the client’s visitors not to operate the PCA pump is crucial. Only the patient should administer doses to prevent overdose.

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A nurse is collecting data from a client who received diphenhydramine 1 hr ago after developing an allergic reaction to trimethoprim-sulfamethoxazole.Which of the following statements by the client should indicate to the nurse that the medication is effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer medications to a client through an enteral feeding tube.Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a newly licensed nurse about monitoring morphine patient-controlled analgesia (PCA). Which of the following information should the nurse include?

Correct Answer is D

Explanation

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A nurse is collecting data from a client who received diphenhydramine 1 hr ago after developing an allergic reaction to trimethoprim-sulfamethoxazole.
Which of the following statements by the client should indicate to the nurse that the medication is effective?