A nurse in a provider's office is caring for a client.

Nurses' Notes

3 months ago:

Client seen in provider's office for routine physical. Today:

Client reports dizziness and light-headedness upon standing. Client reports waking up at night to void.

What actions should the nurse take? Select all that apply.

A. Hyperactive bowel sounds: Muscarinic agonist poisoning typically results in increased gastrointestinal motility and hyperactive bowel sounds. Atropine, an anticholinergic medication, works by blocking muscarinic receptors and reducing gastrointestinal motility. Therefore, the presence of hyperactive bowel sounds may indicate ongoing muscarinic stimulation and inadequate treatment with atropine.
B. Heart rate 90/min: Atropine is an anticholinergic medication that increases heart rate by blocking the parasympathetic effects of acetylcholine on the heart. Bradycardia is a common manifestation of muscarinic agonist poisoning, and an increase in heart rate following atropine administration indicates reversal of this effect and effective treatment.
C. Blood pressure 90/50 mm Hg: Atropine administration may result in transient hypertension due to its effect on increasing heart rate and cardiac output. Hypotension is a common
manifestation of muscarinic agonist poisoning, and an increase in blood pressure following atropine administration may indicate improvement in cardiovascular function. Therefore, a blood pressure of 90/50 mm Hg may not necessarily indicate effective treatment with atropine.
D. Increased salivation: Muscarinic agonist poisoning typically results in excessive salivation (sialorrhea) due to stimulation of muscarinic receptors in the salivary glands. Atropine administration works by blocking these muscarinic receptors and reducing salivation. Therefore, increased salivation would indicate ongoing muscarinic stimulation and inadequate treatment with atropine.

A. The client had a decreased neutrophil count before the medication was administered: This finding may be expected in a client undergoing cytotoxic chemotherapy and receiving filgrastim to stimulate neutrophil production. It is not an indication for an incident report.
B. The client had chemotherapy 12 hr before the medication was administered: The timing of chemotherapy administration is not typically a reason to complete an incident report unless it conflicts with specific medication guidelines or protocols.
C. The vial was out of the refrigerator for 2 hr before the medication was administered:

Filgrastim should be stored in the refrigerator and protected from light. Allowing the medication vial to be out of the refrigerator for an extended period may compromise its stability and effectiveness, potentially leading to adverse effects or reduced efficacy. Therefore, this finding warrants completion of an incident report.
D. The client reported feeling nauseous after the medication was administered: Nausea is a known side effect of filgrastim and is not typically an indication for completing an incident report unless it is severe or persistent and requires intervention.