Question

A client asks the nurse about a prescription for the antihistamine, diphenhydramine (Benadryl). The nurse should teach the client that this medication is contraindicated in clients who have a history of which condition?

Answer 1

Correct Answers:

Glaucoma

Rationale :

💥Diphenhydramine (Benadryl) is a first-generation antihistamine with anticholinergic properties, which can cause pupil dilation (mydriasis) and reduce the outflow of aqueous humor, thereby increasing intraocular pressure.

💥This is particularly dangerous for clients with narrow-angle glaucoma, a condition where increased pressure can lead to optic nerve damage and vision loss.

💥The nurse must always assess for a history of glaucoma before advising or administering such medications.

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Answer 2

Correct Answers:

To prevent fluid from accumulating in the wound

Rationale :

✍A Jackson-Pratt (JP) drain is a closed-suction drainage system placed during surgery to continuously remove blood, pus, or other fluids from the operative site.

✍ Accumulation of fluid in the wound can lead to delayed healing, infection, or wound dehiscence.

✍The drain promotes proper healing by preventing these complications and reducing pressure within the surgical area.

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Answer 3

Correct Answers:

Debride

Rationale :

💎Slough is a form of necrotic tissue that appears yellow, tan, or gray and is non-viable.

💎It prevents the formation of healthy granulation tissue and impairs wound healing.

💎The correct management involves debridement, which is the removal of this devitalized tissue by surgical, mechanical, autolytic, or enzymatic methods.

💎Removing slough helps promote a clean wound base conducive to healing.

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Answer 4

Correct Answers:

I plan to write that I do not want them to keep me on a breathing machine.

Rationale :

💎This statement demonstrates a clear understanding of advance directives, which are legal documents allowing clients to express their preferences for life-sustaining treatment in the event of incapacity.

💎The client specifically mentions mechanical ventilation, one of the key decisions outlined in most advance directives.

💎 It reflects autonomy in care and aligns with ethical and legal standards for informed decision-making in healthcare.

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Answer 5

Correct Answers:

Rub soap on hands for 20 seconds-

Rationale :

💥Effective hand hygiene is a cornerstone of infection prevention.

💥According to CDC guidelines, healthcare providers must wash hands for at least 20 seconds using soap and water to remove pathogens and reduce the risk of healthcare-associated infections (HAIs).

💥The friction generated during this time mechanically removes dirt, oils, and microorganisms from the skin.

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Answer 6

Correct Answers:

Pupil dilation

Rationale :

📌Pupil dilation may be noted in clients experiencing neurologic symptoms or complications during pregnancy such as eclampsia or toxemia, where increased intracranial pressure or neurological involvement may be present.

📌 Dilation of the pupils is a critical neurologic sign that nurses assess as part of routine evaluations, especially when caring for pregnant patients who are at risk of preeclampsia or other CNS involvement.

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Answer 7

Correct Answers:

Restlessness

Rationale :

💥Restlessness is an early clinical sign of hypoxia due to the brain's sensitivity to decreased oxygen delivery.

💥Before oxygen levels drop to visibly critical levels, the client may exhibit anxiety, agitation, confusion, or irritability.

💥Early recognition of such subtle signs allows for prompt intervention before hypoxia progresses to more serious complications like cyanosis or respiratory failure.

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Answer 8

Correct Answers:

Take the medication with a full glass of water.

Rationale :

💥Instructing the client to take medication with a full glass of water helps facilitate proper absorption, minimizes irritation of the gastrointestinal tract, and aids in preventing esophageal injury—especially for medications taken at bedtime, when the patient lies down soon after.

💥This practice is essential to reduce complications such as pill-induced esophagitis and ensure drug efficacy.

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Answer 9

Correct Answers:

Keep the line open with 0.9/0 NS through new tubing.

Rationale :

🔹When a transfusion reaction is suspected (e.g., flushing, low-back pain), the nurse must immediately stop the blood transfusion and maintain IV access with new tubing using 0.9% normal saline.

🔹This ensures the client is no longer receiving potentially harmful blood and allows for rapid administration of emergency treatments such as antihistamines or epinephrine if necessary.

🔹Keeping the line open also supports fluid resuscitation if shock occurs.

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Answer 10

Correct Answers:

Health care team members caring for the client

Rationale :

✍Under HIPAA regulations, protected health information (PHI) can only be disclosed to individuals who are directly involved in the client’s care.

✍This includes physicians, nurses, therapists, and other members of the interdisciplinary team who are providing treatment.

✍Sharing information with unauthorized persons—even family—without client consent is a violation of privacy laws.

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RN N103 Fundamentals Final exam

No.

1 : A client asks the nurse about a prescription for the antihistamine, diphenhydramine (Benadryl). The nurse should teach the client that this medication is contraindicated in clients who have a history of which condition?

2 : A nurse is caring for a client who has a Jackson-Pratt (JP) drain in place after surgery for an abdominal wound. The nurse should understand that the JP drain was placed for which purpose?

3 : A nurse is assessing a client's wound and notes there is slough present. What would be an appropriate intervention for this wound?

4 : A nurse is giving preoperative instructions to a patient scheduled for surgery. The patient tells the nurse, "l will prepare my advance directives before I come to the hospital." Which statement shows the client understands advance directives?

5 : A nurse is preparing to perform hand hygiene. Which action should the nurse take for hand hygiene to be effective?

6 : A nurse is caring for a patient who is pregnant. Check the name tag.

7 : Which clinical manifestation is most reflective of an early response to hypoxia?

8 : A nurse is teaching a client who is taking medication before bedtime. The nurse should include the following instructions:

9 : A nurse is assessing a client who is receiving a unit of packed RBCs. The client appears flushed and reports low-back pain. After stopping the transfusion, which intervention is important to complete FIRST?

10 : A nurse is preparing an educational program about client confidentiality. The nurse should explain that nurses may share a client's protected health information with which individuals?

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