During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic with increased oral secretions after receiving edrophonium IV. Vital signs are HR 55, BP 130/78, respiration 12 and saturation of 94%. What intervention should the nurse prepare to do?

Continue to monitor as this is a normal response to the medication

Administration of atropine

Place the patient in the trendelenburg position

Administer diphenhydramine (Benadryl) for the allergic reaction

Answer and Explanation

The Correct Answer is B

A) Continue to monitor as this is a normal response to the medication: The symptoms the patient is experiencing (cramping, diaphoresis, increased oral secretions) are not normal responses to the edrophonium test and suggest a cholinergic crisis rather than a simple reaction to the medication. A cholinergic crisis occurs when there is overmedication with cholinergic drugs, leading to excessive stimulation of the parasympathetic nervous system. While mild effects like slight nausea or dizziness can occur, cramping, diaphoresis, and increased oral secretions indicate toxicity, requiring immediate intervention.

B) Administration of atropine: The symptoms the patient is exhibiting—cramping, diaphoresis, and increased oral secretions—are indicative of cholinergic toxicity. Edrophonium, a cholinesterase inhibitor, is used in the Tensilon test to diagnose myasthenia gravis by temporarily improving muscle strength. However, in some cases, the patient may experience a cholinergic crisis from an overdose of the medication, resulting in excess acetylcholine at synapses, which overstimulates the parasympathetic nervous system. Atropine, an anticholinergic agent, blocks the effects of acetylcholine and is used to reverse these symptoms by reducing the excessive parasympathetic activity (e.g., reducing secretions and improving heart rate).

C) Place the patient in the Trendelenburg position: The Trendelenburg position (head down, feet up) is often used in cases of shock to help increase venous return to the heart. However, it is not appropriate for a cholinergic crisis. The patient’s symptoms are not due to hypotension or shock but are related to an overdose of edrophonium causing parasympathetic overstimulation.

D) Administer diphenhydramine (Benadryl) for the allergic reaction: The symptoms the patient is experiencing (cramping, diaphoresis, increased oral secretions) are not related to an allergic reaction. Diphenhydramine (Benadryl) is an antihistamine used for allergic reactions, such as urticaria or anaphylaxis, but it does not treat cholinergic toxicity.

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Correct Answer is A

Explanation

A) Class II:
According to the New York Heart Association (NYHA) classification of heart failure, Class II is characterized by slight limitation in physical activity. Patients in this class are comfortable at rest but experience symptoms (such as fatigue, palpitations, or shortness of breath) during ordinary physical activity. This description fits the client's reported symptoms, which include comfort at rest and the onset of symptoms with routine activity, such as walking or climbing stairs.

B) Class IV:
Class IV is the most severe stage of heart failure. Patients in this class are unable to carry out any physical activity without discomfort and experience symptoms at rest, such as shortness of breath or fatigue. The symptoms do not improve with rest, and even minimal exertion exacerbates the condition.

C) Class I:
Class I heart failure is characterized by no limitation in physical activity. Patients in this class are able to carry out ordinary physical activity without fatigue, palpitations, or dyspnea. Since this client experiences symptoms with ordinary activity, they do not meet this criteria.

D) Class III:
Class III represents patients with marked limitation of physical activity. They are comfortable at rest, but less than ordinary activity causes fatigue, palpitations, or shortness of breath. While this client does report symptoms with ordinary physical activity, Class III patients experience greater limitation in activity than described in this scenario. The client in this case only has slight limitation with ordinary activity, so Class III does not apply.

A. Respiratoty acidosis B. Metabolic alkalosis C. Respiratory alkalosis D. Metabolic acidosis

Correct Answer is A

Explanation

A) Respiratory acidosis:
This condition is characterized by an increase in PaCO2 and a decrease in pH, which is exactly what is seen in these ABG results. The pH of 7.21 indicates acidosis (normal pH range is 7.35–7.45), and the PaCO2 of 50 is elevated (normal PaCO2 range is 35–45 mmHg), indicating that carbon dioxide retention is contributing to the acidosis. In respiratory acidosis, the lungs are unable to adequately expel CO2, leading to an accumulation of CO2 in the blood, which decreases the pH. The HCO3 (bicarbonate) is within normal range (22–28 mEq/L), suggesting that there has not yet been compensation by the kidneys, which would typically increase bicarbonate levels to buffer the acidosis.

B) Metabolic alkalosis:
Metabolic alkalosis is characterized by an elevated pH (above 7.45) and an elevated HCO3 (above 28 mEq/L). In this case, the pH is low (7.21), and the bicarbonate level (HCO3) is normal (26), so metabolic alkalosis is not the correct diagnosis.

C) Respiratory alkalosis:
Respiratory alkalosis occurs when there is decreased PaCO2 (below 35 mmHg) and an elevated pH (above 7.45), typically due to hyperventilation. Since the PaCO2 is elevated (50 mmHg) in this case, it rules out respiratory alkalosis.

D) Metabolic acidosis:
Metabolic acidosis is characterized by a low pH (below 7.35) and a low HCO3 (below 22 mEq/L). While the pH is low in this case, the HCO3 is normal (26 mEq/L), which suggests that the acidosis is not metabolic in origin. Metabolic acidosis would typically show a low bicarbonate level, indicating that the kidneys are not able to compensate effectively.

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a client who is diagnosed with heart failure and reports slight limitation of physical activity, is comfortable at rest but ordinary physical activity causes symptoms. What heart failure classification does this patient fall under?

Correct Answer is A

Explanation

What condition do these results indicate? A nurse is reviewing arterial blood gas lab values on her newly admitted elderly client. The ABG results are as follows: pH 7.21, PaCO2 50, HCO3 26.

Correct Answer is A

Explanation

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