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.)
Nonproductive cough
Drowsiness
Urinary retention
Dry mouth
Skin rash
Correct Answer : C,D
A. Nonproductive cough: Diphenhydramine is an antihistamine, not a cough suppressant. It does not cause a nonproductive cough as a side effect.
B. Drowsiness: First-generation antihistamines (like diphenhydramine) cause CNS depression, leading to drowsiness.
C. Urinary retention: Diphenhydramine has anticholinergic effects, which can lead to urinary retention, especially in older adults or those with prostate issues.
D. Dry mouth: Diphenhydramine blocks muscarinic receptors, reducing saliva production and causing dry mouth.
E. Skin rash: Skin rash is not a common adverse effect of diphenhydramine but can be a sign of an allergic reaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
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.
Correct Answer is A
Explanation
A. Call the health care provider, a blockage is present in the tubing: A sudden decrease in drainage can indicate a blockage in the tubing, which could lead to fluid buildup and infection. The provider should be notified so that interventions can be taken (e.g., irrigation, assessment for clot formation).
B. Remove the drain, a drain is no longer needed: The nurse should not remove the drain without a provider’s order. A decrease in drainage does not necessarily mean the wound has healed.
C. Do nothing as long as the evacuator is compressed. Even if the evacuator is compressed, a sudden decrease in drainage is abnormal and requires further investigation. Ignoring it can lead to complications like hematoma or infection.
D. Chart the results on the intake and output flow sheet. While documenting the change is important, charting alone is not an appropriate intervention. The nurse must also assess for possible causes of the decreased drainage and notify the provider.
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