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 ["B","C","D"]
Explanation
A. Sit up comfortably in the bed is incorrect; the client should be in an upright position, which can be done while sitting up comfortably, but it’s essential to emphasize a more upright posture for optimal administration.
B. Tilt the head slightly to the side is correct; this position helps facilitate the delivery of the medication into the nasal passages.
C. Insert the tip of the nose piece into one nostril is correct; proper insertion ensures effective delivery of the medication.
D. Hold the breath for a few seconds after administering the spray is correct; this allows the medication to be absorbed more effectively.
E. Blow the nose 1 minute after administering the spray is incorrect; clients should avoid blowing their nose immediately after use to allow for proper absorption of the medication.