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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Has the child eaten recently? This is the correct and most important question to ask before administering insulin. The timing and content of the child's recent meals will directly impact their blood sugar levels and help determine the appropriate insulin dose. Insulin is typically administered in correlation with meals to maintain blood sugar within a target range and prevent hypo- or hyperglycemia.
A. Did the child perform a fingerstick? While checking the child's blood glucose level is an important part of diabetes management, it is not the most crucial piece of information to gather before administering insulin. The PN should prioritize knowing whether the child has eaten recently, as insulin administration should be coordinated with meals to prevent hypoglycemia or hyperglycemia.
B. How much did the child exercise today? Physical activity can affect blood sugar levels, but it is not the most critical information to obtain before administering insulin. The PN should focus on the child's food intake because insulin doses need to be adjusted accordingly to prevent fluctuations in blood sugar levels.
C. When did the child last urinate? While monitoring urinary patterns is important in assessing hydration and kidney function, it is not directly related to determining the appropriate insulin dose. The PN should prioritize gathering information about the child's recent food intake, as insulin administration needs to be coordinated with meals.
Correct Answer is D
Explanation
This is the best action to take for a client who experiences a sudden gush of vaginal blood and clots after a cesarean section. Massaging the fundus helps to stimulate uterine contractions and reduce bleeding. Avoiding direct pressure on the incision prevents pain and wound dehiscence.
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