NURSING PROCESS APPROACH 2026
COMPREHENSIVE ASSESSMENT
◉ A patient complains of a sore throat and has been told it is due to
beta-hemolytic streptococcal infection. The nurse anticipates that
the patient has which acute condition?
A. Rhinitis
B. Sinusitis
C. Pharyngitis
D. Rhinorrhea. Answer: C. Pharyngitis
◉ A patient is prescribed a decongestant nasal spray that contains
oxymetazoline. What will the nurse teach the patient?
A. Take this drug at bedtime because it may cause drowsiness.
B. Directly spray the medication away from the nasal septum and
gently sniff.
C. This drug may be used in maintenance treatment for asthma.
D. Limit use of the drug to 5 to 7 days to prevent rebound nasal
congestion. Answer: D. Limit use of the drug to 5 to 7 days to prevent
rebound nasal congestion
,◉ A patent has been prescribed guaifensin. The nurse understands
that the purpose of the drug is to accomplish what?
A. Treat allergic rhinitis and prevent motion sickness
B. Loosen bronchial secretions so coughing can eliminate them
C. Complete with histamine for receptor sites, thus preventing a
histamine response.
D. Stimulate alpha-adrenergic receptors, thus producing vascular
constriction of capillaries in nasal mucosa. Answer: B. Loosen
bronchial secretions so coughing can eliminate them
◉ Beclomethasone has been prescribed for a patient with allergic
rhinitis. What should the nurse teach the patient regarding this
medications?
A. This may be used for an acute attack.
B. An oral form is available if the patient prefers to use it.
C. Avoid large amounts of caffeine intake because an increased heart
rate may occur.
D. With continuous use, dryness of the nasal mucosa/lining may
occur. Answer: D. With continuous use, dryness of the nasal
mucosa/lining may occur
, ◉ The nurse is teaching a patient about diphenhydramine. Which
instructions should the nurse include in the patient's teaching plan?
(Select all that apply)
A. Take medication on an empty stomach to facilitate absorption
B. Avoid alcohol and other central nervous system depressants.
C. Notify a health care provider if confusion or hypotension occurs
D. Use sugarless candy, gum, or ice chips for temporary relief of dry
mouth.
E. Avoid handling dangerous equipment or performing dangerous
activities until stabilized on the medication. Answer: B. Avoid
alcohol and other central nervous system depressants.
C. Notify a health care provider if confusion or hypotension occurs
D. Use sugarless candy, gum, or ice chips for temporary relief of dry
mouth.