A nurse is caring for a client with myasthenia gravis who is exhibiting signs of cholinergic crisis. Which medication does the nurse ensure is available to treat this crisis?

Atropine sulfate

Pyridostigmine bromide (Mestinon)

Protamine sulfate

Acetylcysteine (Mucomyst)

Answer and Explanation

The Correct Answer is A

Choice A Reason: Atropine sulfate is the medication that the nurse should ensure is available to treat cholinergic crisis, as it blocks the effects of acetylcholine and reverses the symptoms of excessive parasympathetic stimulation.

Choice B Reason: Pyridostigmine bromide (Mestinon) is not the medication that the nurse should ensure is available to treat cholinergic crisis, but it is used to treat myasthenia gravis by increasing acetylcholine levels and improving muscle strength.

Choice C Reason: Protamine sulfate is not the medication that the nurse should ensure is available to treat cholinergic crisis, but it is used to reverse the effects of heparin and prevent bleeding.

Choice D Reason: Acetylcysteine (Mucomyst) is not the medication that the nurse should ensure is available to treat cholinergic crisis, but it is used to treat acetaminophen overdose and prevent liver damage.

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Correct Answer is C

Explanation

Choice A Reason: Applying a transparent dressing to the drain site is not an appropriate action for the nurse to take, as it may trap moisture and bacteria and increase infection risk.

Choice B Reason: Clamping the tubing when the client ambulates is not an appropriate action for the nurse to take, as it may cause bile accumulation and leakage and increase pressure and pain.

Choice C Reason: Placing the client into Fowler's position is an appropriate action for the nurse to take, as it helps to promote drainage and prevent reflux of bile into the liver.

Choice D Reason: Securing the tubing to the client's gown is not an appropriate action for the nurse to take, as it may cause tension and displacement of the drain and increase discomfort and bleeding.

A. Instruct the client to increase fluid intake. B. Notify the health care provider. C. Advise the client to take iron rich foods. D. Document the findings.

Correct Answer is B

Explanation

Choice A Reason: Instructing the client to increase fluid intake is not the most appropriate nursing action, as it does not address the cause or severity of the bleeding.

Choice B Reason: Notifying the health care provider is the most appropriate nursing action, as it indicates that the client may have a bleeding ulcer that requires immediate evaluation and treatment.

Choice C Reason: Advising the client to take iron rich foods is not the most appropriate nursing action, as it does not prevent or correct anemia or bleeding.

Choice D Reason: Documenting the findings is not the most appropriate nursing action, as it does not initiate any intervention or outcome.

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A nurse is caring for a client with myasthenia gravis who is exhibiting signs of cholinergic crisis. Which medication does the nurse ensure is available to treat this crisis?

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