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 A
Explanation
Repositioning the client helps alleviate any discomfort or pressure points that may be interfering with their ability to find a comfortable sleeping position. Providing a back rub can promote relaxation and help the client feel more comfortable.
It is important to address non-pharmacological interventions first before considering medication options. In this case, repositioning and providing a back rub are non-invasive, non-pharmacological interventions that can be effective in promoting sleep.
B. Offering a cup of hot chocolate at bedtime may not address the underlying cause of the client's difficulty in sleeping and may not be the most appropriate intervention at this time.
C. Similarly, administering a prescribed sleep medication should only be considered after non-pharmacological interventions have been attempted and if deemed necessary by the healthcare provider.
D. Administering an as-needed (PRN) prescription for pain may be appropriate if pain is contributing to the client's difficulty in sleeping. However, repositioning and providing a back rub can be the initial interventions to address discomfort and pain before considering additional pain medication.
Correct Answer is ["500ml"]
Explanation
1 liter is equal to 1000 milliliters. Therefore, to calculate the fluid intake in mL, we can multiply 1/2 liter by 1000 mL/liter:
1/2 liter * 1000 mL/liter = 500 mL
So, the practical nurse should document 500 mL as the client's fluid intake.
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