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

Answer and Explanation

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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Correct Answer is B

Explanation

A. Fresh fish

Fresh fish does not contain significant amounts of tyramine. Therefore, there is no need to eliminate fresh fish from the client's diet due to its interaction with selegiline.

B. Cheddar cheese

This is the correct answer. Cheddar cheese is a high-tyramine food and should be eliminated from the client's diet when taking MAOIs. Aged cheeses, such as cheddar, contain high levels of tyramine due to the fermentation process, which can increase the risk of a hypertensive crisis when combined with MAOIs.

C. Cherries

Cherries do not contain significant amounts of tyramine. Therefore, there is no need to eliminate cherries from the client's diet due to their interaction with selegiline.

D. Chicken

Chicken does not contain significant amounts of tyramine. Therefore, there is no need to eliminate chicken from the client's diet due to its interaction with selegiline.

A. Placing padding around or under the patient's head B. Positioning the patient on the side once the relaxation stage is entered to allow oral secretions to drain C. Have the necessary equipment and/or personnel in case the patient doesn't spontaneously breath when the seizure is over D. Insert a tongue depressor in the patient's mouth E. Note the time the seizure started F. Hold the patient down to prevent injury

Correct Answer is ["A","B","C","E"]

Explanation

A. Placing padding around or under the patient's head

This is a helpful instruction to include. Placing padding around or under the patient's head can help prevent injury during a seizure by cushioning the head against impact with the ground.

B. Positioning the patient on the side once the relaxation stage is entered to allow oral secretions to drain

This is a correct instruction. Positioning the patient on their side (recovery position) can help prevent aspiration if vomiting occurs during or after the seizure. It also helps clear oral secretions and maintain a clear airway.

C. Having the necessary equipment and/or personnel in case the patient doesn't spontaneously breathe when the seizure is over

This is an important instruction. It is crucial to have emergency equipment (such as oxygen and suction) readily available and to be prepared to provide respiratory support if the patient does not spontaneously breathe after the seizure.

D. Inserting a tongue depressor in the patient's mouth

This is an incorrect instruction. It is not recommended to insert anything into the patient's mouth during a seizure as it can cause injury to the teeth, gums, or airway. Additionally, it is a common misconception that tongue swallowing occurs during seizures, which is rare.

E. Noting the time the seizure started

This is a critical instruction. Noting the time the seizure started helps healthcare providers assess the duration of the seizure and determine if medical intervention is necessary. It also helps monitor the patient's recovery and response to treatment.

F. Holding the patient down to prevent injury

This is an incorrect instruction. Holding the patient down during a seizure can cause injury to both the patient and the person restraining them. It is important to create a safe environment by removing hazards and guiding the patient away from dangerous objects or situations, but holding them down is not appropriate.

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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:

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