A client with irritable bowel syndrome (IBS) is receiving dicyclomine, an anticholinergic drug. Prior to administering the next dose, the practical nurse (PN) determines that the client's mucous membranes are dry, and the client reports having a dry mouth. Which action should the PN take
Check vital signs.
Notify the charge nurse.
Monitor hemoglobin.
Provide oral care.
Observe and report any ear drainage after removing the device.
The Correct Answer is D
Dry mucous membranes and a dry mouth are common side effects of anticholinergic drugs like dicyclomine. These medications block the action of acetylcholine, a neurotransmitter responsible for stimulating secretions in the body. As a result, the client may experience dryness in various parts of the body, including the mouth.
Providing oral care, such as offering the client sips of water or providing a moistening agent for the mouth, can help alleviate the discomfort caused by dryness and promote oral hygiene. It is an appropriate and immediate intervention for the client's current symptoms.
Incorrect:
A. Checking vital signs may not directly address the client's dry mouth, but it is a good practice to assess the client's overall condition.
B. Monitoring hemoglobin would not be necessary in this situation, as it does not directly relate to the client's dry mucous membranes.
C. Notifying the charge nurse may be appropriate if the client's symptoms worsen or if there are other concerning factors, but the priority action in this case is to provide oral care to address the client's discomfort.
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Related Questions
Correct Answer is C
Explanation
This is the correct answer because it is the most important and relevant action that the PN should do for a postoperative patient with a PCA machine. A PCA machine is a computerized device that allows the patient to self-administer a preset dose of pain medication, usually an opioid, by pressing a buton. The PCA machine is attached to an intravenous (IV) line that delivers the medication directly into the bloodstream. The PCA machine can provide effective and individualized pain relief for postoperative patients, as well as increase their sense of control and satisfaction¹².
The PN should assess the pain management response of the postoperative patient with a PCA machine by monitoring their pain level, vital signs, oxygen saturation, sedation level, and side effects. The PN should use a valid and reliable pain scale, such as the numeric rating scale (NRS) or the visual analog scale (VAS), to measure the patient's pain intensity and relief. The PN should also check the settings and functioning of the PCA machine, such as the dose, lockout interval, and limit. The PN should document and report the patient's pain management response and any problems or complications with the PCA machine to the health care provider.
Correct Answer is A
Explanation
Worsening perineal pain after medication could indicate inadequate pain relief or a potential complication such as infection or hematoma. It is important to reassess the client to determine the cause of the increased pain and take appropriate action before transferring to the postpartum unit.
The other scenarios described in the options may also require attention, but they do not indicate an immediate need for reassessment before transfer:
B. A primigravida who passed a small clot when she sat up on the edge of the bed: Passing small clots is a normal part of the postpartum period, and it may not necessarily require immediate reassessment. However, the PN should monitor for any excessive or large clots and report any concerning findings.
C. A multigravida whose peri-pad is 1⁄2 saturated with lochia rubra after one hour: Lochia rubra is the normal discharge following childbirth, and some saturation of the peri-pad is expected.
However, the PN should continue to monitor the amount and consistency of the lochia and report any significant changes.
D. A multigravida complaining of strong afterbirth pains when breastfeeding: Afterbirth pains, also known as uterine cramps, are common during breastfeeding as the uterus contracts. While discomfort is expected, strong afterbirth pains should be assessed for severity and managed appropriately. The PN should provide comfort measures and assess if the pain is within the expected range or if it requires further evaluation.
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