The nurse is caring for a patient taking a cholinergic agent. When auscultating lung sounds, the nurse notes inspiratory and expiratory wheezing bilaterally. The best action for the nurse to take would be to:
withhold the next dose and notify the physician
give the next dose
assess heart rate
assess blood pressure
The Correct Answer is A
A. Withhold the next dose and notify the physician:
Withholding the next dose of the cholinergic agent is the appropriate immediate action because the presence of inspiratory and expiratory wheezing bilaterally suggests bronchoconstriction or bronchospasm, which can be a serious adverse reaction to the medication. Notifying the physician promptly allows for further assessment and management of the patient's respiratory symptoms. The physician may need to adjust the medication regimen, order diagnostic tests, or provide treatment for bronchoconstriction.
B. Give the next dose:
Administering the next dose of the cholinergic agent could worsen the patient's respiratory symptoms and exacerbate bronchoconstriction. This action is contraindicated in the presence of wheezing, as it may further compromise the patient's respiratory function.
C. Assess heart rate:
While assessing heart rate is an important aspect of patient assessment, it is not the priority in this scenario. The priority is to address the respiratory distress and potential bronchoconstriction associated with the cholinergic agent. Wheezing is a respiratory symptom that suggests airway obstruction, and immediate intervention is necessary to ensure adequate oxygenation and ventilation.
D. Assess blood pressure:
Similarly, while assessing blood pressure is important in patient care, it is not the priority in this situation. The priority is to address the respiratory distress and potential bronchoconstriction associated with the cholinergic agent. Wheezing indicates respiratory compromise, and prompt action is required to prevent further respiratory deterioration.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Excessive salivation:
Excessive salivation is not a common adverse effect of benztropine. Instead, anticholinergic medications like benztropine often cause dry mouth, which is more common than excessive salivation.
B. Difficulty voiding:
Difficulty voiding, or urinary retention, is a potential adverse effect of anticholinergic medications like benztropine. Anticholinergic drugs can cause relaxation of the detrusor muscle in the bladder, leading to urinary retention. Therefore, the nurse should instruct the client to report any difficulty or inability to urinate.
C. Diarrhea:
Diarrhea is not a common adverse effect of benztropine. Instead, anticholinergic medications like benztropine typically cause constipation due to their antimuscarinic effects on the gastrointestinal tract.
D. Slow pulse:
Slow pulse, or bradycardia, is not a common adverse effect of benztropine. Instead, anticholinergic medications like benztropine may cause tachycardia (increased heart rate) due to their effects on the autonomic nervous system.
Correct Answer is ["0.6"]
Explanation
To calculate the dose of diazepam in mL, the nurse should use the formula:
Dose (mL) = Desired dose (mg) / Available dose (mg/mL)
Plugging in the values from the question, we get:
Dose (mL) = 3 mg / 5 mg/mL
Simplifying, we get:
Dose (mL) = 0.6 mL
Therefore, the nurse should administer 0.6 mL of diazepam IM.
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