Which patient should be advised by the nurse to avoid over-the-counter cold and allergy preparations that contain phenylephrine?
A 47-year-old female with hypertension
A 52-year-old male with adult-onset diabetes
A 17-year-old female with symptoms of an upper respiratory infection
A 62-year-old male with gout
The Correct Answer is A
A. Phenylephrine is a decongestant that can raise blood pressure, making it contraindicated for individuals with hypertension. Advising a patient with hypertension to avoid phenylephrine is essential to prevent potential cardiovascular complications.
B. While patients with diabetes should be cautious about certain medications, phenylephrine is not specifically contraindicated in this condition.
C. A 17-year-old female with an upper respiratory infection typically does not have contraindications for phenylephrine unless there are underlying conditions not mentioned.
D. Gout does not have a direct contraindication for phenylephrine use, so the patient may not need to avoid it unless other health issues are present.
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Correct Answer is A
Explanation
A. Administering a stool softener is essential as opioids like morphine commonly cause constipation, and this proactive measure helps mitigate that adverse effect.
B. While auscultating the lungs is important to monitor respiratory function, it does not specifically address a common adverse effect of morphine.
C. Encouraging active range of motion exercises can help prevent complications from immobility but does not directly address the most common adverse effect of morphine.
D. Applying calf compressors can help prevent deep vein thrombosis, but it is not the most effective action for addressing the specific adverse effects of morphine use.
Correct Answer is ["A","B","C"]
Explanation
A. Auscultating bowel sounds is important because anticholinergic agents can decrease gastrointestinal motility, leading to reduced bowel sounds and potential constipation.
B. Monitoring urine output is crucial as anticholinergics can cause urinary retention, and assessing output helps identify any adverse effects on bladder function.
C. Monitoring heart rate is necessary since anticholinergic agents can cause tachycardia as a side effect, making it important to assess the client’s cardiovascular status.
D. Administering an antidiarrheal agent is not typically indicated, as anticholinergic agents often cause constipation rather than diarrhea.
E. Assessing deep tendon reflexes is not directly relevant to the effects of anticholinergic medications and is not typically prioritized in this context.