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RN 231 Quiz 4_Cloned_Assessment 1
- A nurse is caring for a client admitted to the emergency department with extensive partial and full -thickness burns of the head, neck, and chest. While planning the client's care, the nurse should be aware that initially the client is at greatest risk for Click here for answers https://bit.ly/2PWmJNI
A. airway obstruction.
Rationale: Burns of the head, neck, and chest may involve damage to the pulmonary tree due to heat as well as smoke and soot inhalation. This can result in severe respiratory difficulty. Nursing measures to maintain a patent airway should take priority in this client's care.
B. infection.
Rationale: Although prevention of infection is an important aspect of burn care throughout hospitalization and treatment, there is a greater initial priority for this client.
C. fluid imbalance.
Rationale: Although adequate fluid replacement is an important aspect of burn care throughout the acute phase of burn treatment, there is a greater initial priority for this client.
D. paralytic ileus. Click here for answers https://bit.ly/2PWmJNI
Rationale: Although paralytic ileus may occur during the acute phase aspect of burn care and may require nasogastric suctioning, there is a greater initial priority for this client.
- A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is pending an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?
A. "Large incisions will be made in the eschar to improve circulation."
Rationale: An escharotomy is a surgical incision made to release pressure and improve circulation in a part of the body that has a deep burn and is experiencing excessive swelling. Burn injuries that encircle a body part, such as an arm or the chest, can cause swelling and tightness in the affected area, resulting in reduced circulation. Making surgical incisions into the burned tissue allows the skin to expand, reduces tightness and pressure, and improves circulation.
B. "I can call the doctor back here if you want me to."
Rationale: This is a nontherapeutic response that defers the client's concern and puts it on hold.
C. "A piece of skin will be removed and grafted over the burned area."
Rationale: A surgical procedure in which a piece of skin from one area of the client's body is transplanted to another area is called a skin graft. Click here for answers https://bit.ly/2PWmJNI
D. "Dead tissue will be surgically removed."
Rationale: Debridement is the surgical removal of dead tissue.
RN 231 Quiz 4_Cloned_Assessment 1
- A group of college students was attending a weekend football rally when one of the students stumbled and fell into the bonfire. Although several friends quickly intervened, the client sustained partial-thickness burns to both lower legs, chest, and both forearms. Which of the following is the priority nursing action when the client is brought into the emergency room? Click here for answers https://bit.ly/2PWmJNI
A. Cover the burned area with sterile gauze.
Rationale: Infection is one of the leading causes of death with burn injuries. Because the integrity of the skin is breeched, it is vital to cover all burned areas with sterile gauze; however, this is not the priority concern at this time.
B. Inspect mouth for signs of inhalation injuries.
Rationale: Since the client sustained burns to the chest, there is a possibility that flames and smoke from the client's burning clothes could have caused an inhalation injury. The nurse should inspect the mouth and throat for soot and swelling. Using the airway, breathing, circulation (ABC) priority-setting framework, this is the priority concern at this time.
C. Administer intravenous pain medication.
Rationale: Because of the large percentage of burned area, this client will experience high levels of pain, since partial-thickness burns expose fragile nerve endings. Large doses of intravenous morphine or other narcotic analgesics will likely be needed for adequat e pain control. Despite the fact that pain is an important issue, it is not the priority concern at this time.
D. Draw blood for a complete blood cell (CBC) count.
Rationale: Burn injuries, such as this one, that exceed 20% of body surface area are considered major burns, which affect the client’s metabolism, hemodynamic balance, and immune system. In the early stage of burns, increased capillary permeability allows sodium to enter cells while potassium leaks out, resulting in hyponatremia and hyperkalemia. An altered osmotic gradient and loss of intravascular fluid causes elevated hematocrit levels. Initial lab studies are important to create a baseline because of these systemic effects of burns. Those labs would include a CBC, electrolytes, BUN, creatinine, and blood glucose. While it is important to establish baseline data, it is not the priority concern at this time.
- A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines the nurse should document burns to which percentage of the client’s total body surface area (TBSA)? Click here for answers https://bit.ly/2PWmJNI
A. 9 percent
Rationale: Each arm represents 9% of the client’s TBSA.
B. 18 percent
Rationale: Each leg represents 18% of the client’s TBSA.
C. 36 percent
Rationale: Both legs represent 36% of the client’s TBSA.
D. 54 percent
Rationale:
RN 231 Quiz 4_Cloned_Assessment 1
This intervention does not address the client’s need for emotional support and may violate client confidentiality.
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- A nurse is assessing the depth and extent of a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the first priority when assessing the severity of the burn?
A. Age of the client
Rationale: The client’s age is important in the assessment of the client’s burns, but is not the priority.
B. Associated medical history
Rationale: The client’s associated medical history is important in the assessment of the client’s burns, but is not the priority.
C. Location of the burn
Rationale: When using the urgent vs. nonurgent approach to care, the nurse determines the priority is to assess the location of the burns that may lead to respiratory distress.
D. Cause of the burn
Rationale: The client’s cause of the burns is important in the assessment of the client’s burns, but is not the priority.
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- A nurse is monitoring the fluid replacement of a client who has sustained burns. Which of the following fluids is used in the first 24 hr following a burn injury?
A. 5% dextrose in water
Rationale: 5% dextrose in water is not the fluid used in the first 24 hr following a burn injury because a stress-induced pseudodiabetes often occurs after major burns and the administration of more dextrose would increase the possibility of hyperosmolar disease.
B. 5% dextrose in normal saline
Rationale: 5% dextrose in normal saline is not the fluid used in the first 24 hr following a burn injury because a stress-induced pseudodiabetes often occurs after major burns and the administration of more dextrose would increase the possibility of hyperosmolar disease.
C. Normal saline
Rationale: Normal saline is not the fluid used in the first 24 hr following a burn injury because the burn causes generalized increased capillary permeability and crystalloids leak out of the burn area into areas such as the pulmonary interstitial spaces and may cause pulmonary edema.
D. Lactated Ringer’s
Rationale: Lactated Ringer’s is a fluid used in the first 24 hr following a burn injury.
RN 231 Quiz 4_Cloned_Assessment 1
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- A nurse is caring for a client with burns to face, ears, and eyelids. Which of the following is the priority finding to report to the provider?
A. Urinary output 25 mL/hr
Rationale: While a urinary output of 25 mL/hr is below the expected output of 30 – 50 mL/hr and should be reported to the provider, this is not the priority finding to report.
B. Difficulty swallowing
Rationale: Difficulty swallowing is an indication that the client’s airway is becoming obstructed, and is the priority to report to the provider.
C. Heart rate 122 beats/min
Rationale: While a heart rate of 122 beats/min is above the expected reference range and should be reported to the provider, this is not the priority finding to report.
D. Lip edema
Rationale: While lip edema is not an expected finding and should be reported to the provider, this is not the priority finding to report.
- A client arrives at the emergency department following an explosion at a chemical plant. He has deep partial- and full-thickness chemical burns over more than 25% of his body surface area. What is the nurse’s priority intervention for this client?
A. Initiate fluid resuscitation.
Rationale: The client will require fluid resuscitation, but this is not the highest priority at this time.
B. Medicate for pain.
Rationale: The client will require pain medication, but this is not the highest priority at this time.
C. Administer antibiotics.
Rationale: The client will require antibiotics, but this is not the highest priority at this time.
D. Maintain a patent airway.
Rationale: The priority action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to keep the client’s airway patent, as the smoke and other irritants from the workplace explosion can cause swelling that can obstruct the trachea.
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- A nurse is planning care for a client who has a GI bleed. Which of the following actions should the nurse take first?
A. Assess orthostatic blood pressure.
Rationale:
RN 231 Quiz 4_Cloned_Assessment 1
C. Gag reflex
Rationale: The greatest risk to the client’s safety following endoscopy is aspiration. Until the client’s gag reflex returns, the nurse must keep to client NPO and prepare to intervene to keep the airway open and unobstructed.
D. Level of consciousness
Rationale: Following endoscopy, the nurse should monitor the client’s level of consciousness, but there is a higher priority in monitoring this client.
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- A client is admitted with an active upper gastrointestinal (GI) bleed. After inserting a NG tube into the client, which of the following findings should the nurse anticipate?
A. Bright red drainage
Rationale: Red drainage indicates an active upper GI bleed.
B. Dark amber drainage
Rationale: Dark amber is generally the color used to describe the urine output of clients who are dehydrated.
C. "Coffee-ground" drainage
Rationale: "Coffee-ground" drainage or emesis indicates an old gastrointestinal bleed, or one that has been resolved.
D. Greenish yellow drainage
Rationale: Greenish yellow drainage is normal NG drainage representative of bile.
- A client is receiving pancreatic enzymes as a digestive aid. The nurse should tell the client expect which of the following gastrointestinal changes?
A. Increased mucus in stools
Rationale: Clients do not take pancreatic enzymes to treat inflammatory bowel disease.
B. Decreased black tarry stools
Rationale: Clients do not take pancreatic enzymes to treat gastrointestinal bleeding.
C. Increased watery stools
Rationale: Although large doses of pancreatic enzymes can cause diarrhea, the usual dosing protocols should not cause this effect.
D. Decreased fat in stools Click here for answers https://bit.ly/2PWmJNI
Rationale: Clients who have cystic fibrosis or pancreatitis, for example, need to supplement meals with
RN 231 Quiz 4_Cloned_Assessment 1
oral pancreatic enzymes to reduce the fat content in their stools. Clients receiving pancreatic enzymes as a digestive aid should expect to have a reduction of fat in their stools.
- A triage nurse in an emergency department is caring for a client who has a gunshot wound to the right side of her chest. The nurse notes a thick dressing on the chest and a sucking noise coming from the wound. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rat e of 40/min. Which of the following actions should the nurse take initially?
A. Raise the foot of the bed to a 90° angle.
Rationale: Trendelenburg position increases pressure on the heart and lungs and is contraindicated for a client who has an open chest wound.
B. Remove the dressing to inspect the wound.
Rationale: A dressing should not be removed from a sucking chest wound until immediately prior to chest tube insertion. Removal of the dressing will cause an increase in size of the pneumothorax and increased respiratory difficulty.
C. Prepare to insert a central line.
Rationale: Although the client may need IV access, a central line is not usually needed in this situation.
D. Administer oxygen via nasal cannula.
Rationale: The client has an increased respiratory rate and heart rate, indicating that she is having respiratory difficulty. Administering oxygen will increase the oxygen exchange in the lungs and the oxygen available to the tissues.
- A nurse in an emergency department is caring for a client who was bitten on the left leg by a poisonous snake. The client has placed elastic bandages snuggly above and below the bite marks and is in no apparent distress. The nurse should
A. discharge the client.
Rationale: Discharging the client is not indicated. The client needs to be treated and assessed by the nurse.
B. obtain a prescription for the appropriate anti-venom.
Rationale: Anti-venom is used to treat the bites of certain poisonous snakes. The appropriate anti -venom must be administered for the specific species of snake.
C. remove both of the elastic bandages from the leg.
Rationale: Releasing the bandages prior to administering the appropriate anti-venom may allow the spread of the venom, resulting in serious systemic consequences.
D. obtain an order for pain medication.
Rationale: Obtaining an order for pain medication is not indicated and may mask other symptoms the
RN 231 Quiz 4_Cloned_Assessment 1
- A nurse is triaging clients in the emergency department. Which of the following clients should the nurse request the provider should see first?
A. A toddler who has asthma and has a pulse oximetry reading of 95% while receiving oxygen at 2 L/min.
Rationale: A pulse oximetry reading of 95% while receiving oxygen at 2 L/min is an expected finding for a toddler who has asthma. This client is not the priority.
B. A toddler who has otitis media, a temperature of 39.2 ° C (102.6° F) and purulent ear discharge.
Rationale: An elevated temperature and purulent ear drainage are expected findings for a toddler who has otitis media. This client is not the priority.
C. A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough.
Rationale: A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough is unstable and requires immediate medical attention; therefore, this client is the highest priority and the nurse should attend to this client first.
D. An adolescent who has sickle cell disease, reports pain level of 7 on a scale of 0 to 10, and requests pain medication.
Rationale: Report of pain level of 7 on a scale of 0 to 10, and request for pain medication are expected findings for an adolescent who has sickle cell disease. This client is not the priority.
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- A nurse is caring for a client who enters the emergency department of severe chest pain. Which of the following interventions should the nurse implement to determine if the client is experiencing a myocardial infarction?
A. Check the client's blood pressure.
Rationale: The nurse should check the client’s vital signs when chest pain is present; however, these findings will not determine if the client is experiencing a myocardial infarction.
B. Auscultate heart tones.
Rationale: The nurse should auscultate heart tones as part of a complete assessment when a client complains of chest pain; however, these findings will not determine if the client is experiencing a myocardial infarction.
C. Perform a 12-lead ECG
Rationale: The nurse should perform a 12-lead ECG when a client complains of chest pain to determine if the client is experiencing a myocardial infarction.
D. Determine if pain radiates to the left arm.
Rationale: The nurse should identify the location of pain as part of a complete assessment however radiation to the left arm can be present in other conditions and therefore does not indicate that the client is experiencing a myocardial infarction.
- A nurse in the emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the
RN 231 Quiz 4_Cloned_Assessment 1
following is the priority intervention?
A. Observe for periorbital edema.
Rationale: The nurse should observe for periorbital edema; however, this is not the priority intervention when taking the airway, breathing, circulation (ABC) approach to client care.
B. Evaluate for local edema.
Rationale: The nurse should evaluate for local edema; however, this is not the priority intervention when taking the airway, breathing, circulation (ABC) approach to client care.
C. Auscultate for wheezing.
Rationale: The nurse should first auscultate for wheezing when taking the airway, breathing, circulation (ABC) approach to client care.
D. Monitor for hypotension.
Rationale: The nurse should monitor for hypotension; however, this is not the priority intervention when taking the airway, breathing, circulation (ABC) approach to client care.
- A nurse is caring for a client who is brought into the emergency department immediately following a snake bite to his forearm. The client suspects the snake to be venomous. Which of the following nursing interventions is appropriate?
A. Apply an ice pack to the site of the bite.
Rationale: The client should be kept warm following a snake bite and ice should not be applied to the site.
B. Apply a tourniquet just above the elbow.
Rationale: The application of a tourniquet is generally avoided following a snake bite due to the risk of nerve and tissue damage.
C. Administer a corticosteroid.
Rationale: Corticosteroids are not administered immediately following a snake bite due to the risk of decreasing the effects of antivenin.
D. Place the extremity in a dependent position.
Rationale: The affected area should be placed in a dependent position to decrease the circulation of venom.
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- A nurse in an emergency department is caring for a client who has a deep laceration on her left lower forearm and is bleeding heavily from the wound. Which of the following interventions should the nurse perform first?
A. Apply a tourniquet just above the wound.
Rationale: The application of a tourniquet is appropriate only after other methods fail to control the
RN 231 Quiz 4_Cloned_Assessment 1
approach to client care.
D. Preventing musculoskeletal disability
Rationale: Preventing musculoskeletal disability is not the priority when using the airway, breathing, circulation approach to client care.
- A nurse is caring for a client who is brought to the emergency room and has burn injuries. Which of the following findings indicates a deep partial-thickness burn?
A. Burned area is black in color and pain is absent.
Rationale: This finding indicates a deep full-thickness burn.
B. Burned area is pink in color with blisters present.
Rationale: This finding indicates a superficial partial-thickness burn.
C. Burned area is red in color with eschar present.
Rationale: This finding indicates a deep partial-thickness burn. Additional findings may include moderate edema and reports of pain.
D. Burned area is yellow in color with severe edema.
Rationale: This finding indicates a full-thickness burn.
- An emergency room nurse is caring for a client following an automobile crash. Upon assessment the nurse observes bleeding from the client’s nose. Which of the following interventions is appropriat e?
A. Obtain a culture of the specimen using sterile swabs.
Rationale: The collection of a culture specimen using any type of swab suction is contraindicated because brain tissue may be inadvertently removed at the same time or other tissue damage may result.
B. Allow the drainage to drip onto a sterile gauze pad.
Rationale: The nurse should allow the drainage to drip onto a sterile gauze pad assess for the presence of cerebrospinal fluid. This intervention allows for the collection of data without increasing the risk for further injury.
C. Suction the nose gently with a bulb syringe.
Rationale: Suctioning the nose is contraindicated because brain tissue may be inadvertently removed at the same time or other tissue damage may result.
D. Insert sterile packing into the nares.
Rationale: The nurse should avoid placing anything into the nares due to the risk of causing further injury.
RN 231 Quiz 4_Cloned_Assessment 1
- A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the laboratory to report the client’s troponin levels, the client asks what this blood test will show. The nurse should explain that troponin is
A. an enzyme that indicates damage to brain, heart, and skeletal muscle tissues.
Rationale: Creatine kinase is an enzyme that indicates damage to brain, heart, and skeletal muscle tissue.
B. a protein whose levels reflect the risk for coronary artery disease.
Rationale: Cholesterol is a protein whose levels reflect the risk for coronary artery disease.
C. a heart muscle protein that appears in the bloodstream when there is damage to the heart.
Rationale: Troponin is a myocardial muscle protein that releases into the bloodstream when there is injury to the myocardial muscle. Troponin levels are point-of-care testing for clients who are having or are at risk for having a myocardial infarction.
D. a protein that helps transport oxygen throughout the body.
Rationale: Myoglobin is a heme protein whose function is to distribute oxygen throughout the body.
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- A nurse is working with an emergency response team in caring for a group of people who were creditably exposed to anthrax. Which of the following is the appropriate action for the nurse to take?
A. Place clients in isolation.
Rationale: Clients exposed to anthrax are not contagious; therefore, the nurse is not required to place them in isolation.
B. Initiate client decontamination.
Rationale: Clients exposed to anthrax do not require decontamination
C. Administer to clients an antibiotics.
Rationale: The nurse should administer an antibiotic as prophylaxis to all clients newly exposed to anthrax.
D. Treat clients with antitoxin.
Rationale: The nurse will not administer antitoxin to clients exposed anthrax, but will to those clients exposed to botulism.
- A nurse in the emergency department is caring for a client who is bleeding profusely from a deep laceration on his left lower forearm. After observing standard precautions, which of the following should the nurse plan to do first?
A. Apply a tourniquet just below the elbow.
Rationale:
RN 231 Quiz 4_Cloned_Assessment 1
A nurse should always administer medication he/she has prepared for their client. This is part of the 6 Rights of Medication.
B. Have another nurse finish preparing the medications.
Rationale: A nurse should always prepare the medication as well as administer for their client. This is part of the 6 Rights of Medication.
C. Lock the medicines in a room and finish when the nurse returns from the emergenc y situation.
Rationale: Locking the medication in a secured area until the nurse returns to finish the preparation is the proper action for the nurse to take. This allows the nurse to continue where she left off in the steps of the 6 Rights of Medication and decreases the probability for error.
D. Discard the prepared medications and begin again upon return.
Rationale: A nurse should not discard medication unless she has drawn the incorrect amount of medication or is wasting a medication.
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- An occupational health nurse is instructing workers at an industrial facility in emergency procedures in the event of a traumatic amputation. Which of the following guidelines should the nurse included for preserving the amputated part for possible surgical reattachment? (Select all that apply.)
A. Wrap the part in dry sterile gauze.
B. Place the severed end of the part into crushed ice.
C. Put the severed part in a dry, waterproof plastic bag.
D. Wrap the covered part in an elastic bandage.
E. Prevent contact of the severed part with water.
- A nurse in the emergency department is caring for a client who was injured in a motor-vehicle crash. The client reports dyspnea and severe pain. The nurse notes that his chest moves inward during inspiration and bulges out during expiration. The nurse should suspect which of the following?
A. Atelectasis
Rationale: Atelectasis involves collapsed, airless alveoli.
RN 231 Quiz 4_Cloned_Assessment 1
B. Flail chest
Rationale: Flail chest results from multiple rib fractures that cause instability. During inspiration, the thorax moves inward, and during expiration it bulges out. This paradoxic chest movement prevents adequate ventilation of the injured lung.
C. Hemothorax
Rationale: Hemothorax is blood in the pleural space and involves decreased movement of the involved chest wall.
D. Pneumothorax
Rationale: Pneumothorax is air in the pleural space and involves decreased movement of the involved chest wall.
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- A nurse is in servicing a group of clients at the community center on the early detection for colorectal cancer. The nurse knows that the American Cancer Society recommends that persons who are asymptomatic, have no risk factors, and are age 50 or older should have a rectal examine with fecal occult blood testing every
A. five years.
Rationale: Five years is too long for the client to have this testing completed.
B. six months.
Rationale: Six months is too soon for the client to have this testing completed.
C. one year.
Rationale: One year is too soon for the client to have this testing completed.
D. two years.
Rationale: Two years is the correct time for client to have this testing competed.
- A nurse is in-servicing a group of clients in the community on early detection for colorectal cancer. The nurse knows that the American Cancer Society recommends that men and women beginning at age 50 are at average risk and should have flexible sigmoidoscopy every
A. five years.
Rationale: Five years is the correct time frame for a client to have this testing completed.
B. six months.
Rationale: Six months is too soon for a client to have this testing completed.
C. one year.
Rationale: One year is too soon for a client to have this testing completed.
RN 231 Quiz 4_Cloned_Assessment 1
B. Confine the fire.
C. Extinguish the fire.
- A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss?
A. Body weight
Rationale: Body weight is the most reliable indicator of fluid loss for infants and young children.
B. Skin integrity
Rationale: Impaired skin integrity can indicate dehydration but is not the best indicator of fluid loss.
C. Blood pressure
Rationale: Change in a child's blood pressure can indicate dehydration but is not the best indicator of fluid loss.
D. Respiratory rate
Rationale: Change in a child's respiratory rate can indicate dehydration but is not the best indicator of fluid loss.
- The family of an older adult client brings him to the emergency department after finding him wandering outside. During the initial assessment, the nurse notes that the client flinches when she palpates his abdomen yet responds to questions only by nodding and smiling. Which of the following factors should the nurse identify as a likely explanation for the client's behavior?
A. He is hard of hearing.
Rationale: If the client cannot hear the nurse, he would most likely communicate that.
B. Pain
Rationale: Clients who have pain can usually still provide assessment data.
C. Confusion
Rationale: Since the client was manifesting signs of confusion before coming to the emergency department and currently seems unable to understand or respond to speech, the nurse should determine that the client has confusion.
D. Language barrier
Rationale: Even if the client speaks a different language as the nurse, the family accompanied him. Although the nurse should use a medical interpreter, the family should be able to provide some initial explanations of the facts leading to the visit.
RN 231 Quiz 4_Cloned_Assessment 1
- A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
A. Blood pressure 102/66 mm Hg
Rationale: The nurse should identify this finding as within the expected reference range.
B. Straw-colored urine from an indwelling urinary catheter
Rationale: Straw-colored urine is an expected finding. More information is needed to determine whether to take action in this case.
C. Yellow-green drainage on the surgical incision
Rationale: Thick yellow-green drainage is indicative of an infection and should be reported immediately.
D. Respiratory rate 18/min
Rationale: The nurse should identify this finding as within the expected reference range.
- A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?
A. Abnormally prominent U wave
Rationale: Although U waves are rare, their presence can be associated with hypokalemia, hypertension and heart disease. For a client who has hypokalemia, the nurse should monitor the EKG strip for a flattened T wave, prolonged PR interval, prominent U wave, or ST depression.
B. Elevated ST segment
Rationale: The nurse should identify ST depression as an indication of hypokalemia.
C. Wide QRS
Rationale: The nurse should identify a widened QRS as an indication of hyperkalemia.
D. Inverted P wave
Rationale: Inverted P waves are associated with junctional rhythms.
- A nurse is caring for a client who has poison ivy and is prescribed diphenhydramine. Which of the following instructions should the nurse give regarding the adverse effect of dry mouth associated with diphenhydramine?
A. "Administer the medication with food."
Rationale: Administering diphenhydramine with food might minimize gastrointestinal effects, but wi ll not relieve dry mouth.
