NURS 622 Exam UPDATED ACTUAL
QUESTIONS AND CORRECT ANSWERS
Priority Data Collection:
The nurse interviews the client for subjective data regarding the itching.
The nurse questions the client about her symptoms. What should the nurse ask about first?
A. Hx of skin conditions
B. What has the client done to treat the itching
C. Severity and location of the itching
D. Recent exposure to lice or scabies - CORRECT ANSWER C. Severity and location
This is the priority question. Itching may be a symptom of a more life threatening problem
and the severity needs to be assessed as a priority.
The client states she feels like something is crawling on her skin all over her body.
The nurse questions the client about anaphylaxis. What client cues would indicate the
presence of an anaphylactic reaction? (Select all that apply. One, some, or all options may be
correct.)
A. Drooling
B. Shortness of breath
C. Diaphoresis
D. Flushed or pale skin
E. Tremors or Seizures - CORRECT ANSWER A, B, D
-Drooling is a symptom of a closing airway in an adult client. Closing of the airway may
occur during anaphylaxis.
, -Shortness or breath or wheezing may be present if the airway is compromised due to
anaphylaxis.
-Skin may be flushed or pale related to the reaction.
The client denies difficulty swallowing, shortness of breath, nausea, or dizziness. No
centralized pallor or flushing is noted. The nurse determines that the client is not having an
anaphylactic reaction. The nurse will continue to monitor the client for changes in condition.
The nurse completes the client interview. The client denies history of skin conditions, rashes,
new medications, or changes in toiletry or laundry items. The nurse completes the initial
client interview and determines the client is in need of diphenhydramine to reduce the effects
of the itching. The chart notes parental consent of PRN diphenhydramine.
Fill in the blankThe nurse prepares to administer diphenhydramine 50 mg orally. The tablet is
supplied in a 25 mg dose. How many tablets should the nurse give? (Enter numerical value
only. If rounding is necessary, round to the tenth.) - CORRECT
ANSWER Desired/Have = ?
50mg/25mg= 2 tablets
The nurse teaches the client about diphenhydramine. Which information should the nurse
include? (Select all that apply. One, some, or all options may be correct.)
A. Diphenhydramine blocks the effect of the histamine response to reduce itching.
B. Diphenhydramine products contain aspirin, so observe for signs of bleeding.
C. This medication may cause drowsiness.
D. Blurred vision or loss of balance are potentially serious side effects of this medication.
E. This medication may cause an increase in secretions and moisten mucous membranes. -
CORRECT ANSWER A, C, D
-Diphenhydramine is a H1 receptor antagonist and may be helpful to reduce itching
associated with hives.
-Although considered a minor side effect, diphenhydramine may cause drowsiness.
QUESTIONS AND CORRECT ANSWERS
Priority Data Collection:
The nurse interviews the client for subjective data regarding the itching.
The nurse questions the client about her symptoms. What should the nurse ask about first?
A. Hx of skin conditions
B. What has the client done to treat the itching
C. Severity and location of the itching
D. Recent exposure to lice or scabies - CORRECT ANSWER C. Severity and location
This is the priority question. Itching may be a symptom of a more life threatening problem
and the severity needs to be assessed as a priority.
The client states she feels like something is crawling on her skin all over her body.
The nurse questions the client about anaphylaxis. What client cues would indicate the
presence of an anaphylactic reaction? (Select all that apply. One, some, or all options may be
correct.)
A. Drooling
B. Shortness of breath
C. Diaphoresis
D. Flushed or pale skin
E. Tremors or Seizures - CORRECT ANSWER A, B, D
-Drooling is a symptom of a closing airway in an adult client. Closing of the airway may
occur during anaphylaxis.
, -Shortness or breath or wheezing may be present if the airway is compromised due to
anaphylaxis.
-Skin may be flushed or pale related to the reaction.
The client denies difficulty swallowing, shortness of breath, nausea, or dizziness. No
centralized pallor or flushing is noted. The nurse determines that the client is not having an
anaphylactic reaction. The nurse will continue to monitor the client for changes in condition.
The nurse completes the client interview. The client denies history of skin conditions, rashes,
new medications, or changes in toiletry or laundry items. The nurse completes the initial
client interview and determines the client is in need of diphenhydramine to reduce the effects
of the itching. The chart notes parental consent of PRN diphenhydramine.
Fill in the blankThe nurse prepares to administer diphenhydramine 50 mg orally. The tablet is
supplied in a 25 mg dose. How many tablets should the nurse give? (Enter numerical value
only. If rounding is necessary, round to the tenth.) - CORRECT
ANSWER Desired/Have = ?
50mg/25mg= 2 tablets
The nurse teaches the client about diphenhydramine. Which information should the nurse
include? (Select all that apply. One, some, or all options may be correct.)
A. Diphenhydramine blocks the effect of the histamine response to reduce itching.
B. Diphenhydramine products contain aspirin, so observe for signs of bleeding.
C. This medication may cause drowsiness.
D. Blurred vision or loss of balance are potentially serious side effects of this medication.
E. This medication may cause an increase in secretions and moisten mucous membranes. -
CORRECT ANSWER A, C, D
-Diphenhydramine is a H1 receptor antagonist and may be helpful to reduce itching
associated with hives.
-Although considered a minor side effect, diphenhydramine may cause drowsiness.
