Which assessment finding indicates to the nurse that the prescription bethanechol is effective for a client diagnosed with urinary retention?
Urinary output equal intake.
No terminal urinary dribbling.
Denies stress incontinence.
Absence of xerostomia.
The Correct Answer is A
A) Urinary output equal intake:
This assessment finding suggests that the client is voiding an amount of urine equivalent to their fluid intake, indicating effective bladder emptying. Bethanechol is a cholinergic agonist that stimulates bladder contraction, helping to improve urinary retention by promoting the expulsion of urine from the bladder. Equal urinary output and intake indicate that the bladder is adequately emptying, which is a positive response to bethanechol therapy.
B) No terminal urinary dribbling:
While the absence of terminal urinary dribbling may be an indicator of improved bladder emptying, it is not as definitive as assessing urinary output equal to intake. Terminal urinary dribbling refers to the involuntary loss of urine that occurs after completing urination due to incomplete emptying of the bladder. While its absence may suggest improved bladder emptying, it is not as reliable an indicator as measuring urinary output.
C) Denies stress incontinence:
The absence of stress incontinence, which is the involuntary loss of urine during activities that increase intra-abdominal pressure (such as coughing, sneezing, or lifting), is not directly related to the effectiveness of bethanechol for urinary retention. Bethanechol primarily targets urinary retention by stimulating bladder contraction rather than addressing stress incontinence, which involves weakness of the pelvic floor muscles.
D) Absence of xerostomia:
Xerostomia refers to dryness of the mouth due to decreased saliva production and is a common side effect of anticholinergic medications. Bethanechol, as a cholinergic agonist, may actually increase saliva production and is not typically associated with xerostomia. However, the absence of xerostomia does not directly indicate the effectiveness of bethanechol for urinary retention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) A dimly lit room:
Mydriatic medications cause pupil dilation by stimulating the dilator muscle of the iris. In bright light, dilated pupils can lead to photophobia (sensitivity to light) and discomfort for the client. Therefore, placing the client in a dimly lit room helps to minimize the discomfort associated with increased sensitivity to light. This environment also supports visual acuity and reduces the risk of visual disturbances that can occur with bright light.
B) A warm room temperature:
While maintaining a comfortable room temperature is important for overall client comfort, it is not specifically related to the administration of mydriatic medications. The choice of room temperature may vary based on the client’s preferences and individual comfort needs but is not directly influenced by the use of mydriatic medications.
C) Cool, humidified air:
Cool, humidified air may be beneficial for certain respiratory conditions or for promoting comfort in some clients. However, it is not directly relevant to the administration of mydriatic medications. The choice of room temperature and humidity level should prioritize the client’s overall comfort and specific health needs but does not specifically relate to the effects of mydriatic drugs.
D) A quiet, restful environment:
While providing a quiet, restful environment is important for promoting relaxation and comfort, it is not specifically related to the administration of mydriatic medications. Clients receiving mydriatic drugs may benefit from restful surroundings to minimize stress or anxiety, but this choice does not address the potential visual discomfort associated with pupil dilation induced by mydriatic drugs.
Correct Answer is B
Explanation
A) Expresses that they cannot get enough air to breathe: While this statement suggests respiratory distress, it is not as objective an assessment finding as a respiratory rate of 7 breaths/minute. Objective measurements are typically more reliable indicators for initiating interventions.
B) Respiratory rate of 7 breaths/minute: A respiratory rate of 7 breaths/minute is indicative of respiratory depression, which is a potential side effect of opioid analgesics like morphine sulfate. Naloxone is an opioid antagonist used to reverse opioid-induced respiratory depression. Administering a prescribed PRN dose of naloxone is appropriate to counteract the respiratory depression and prevent further complications.
C) Bilateral wheezing on auscultation: Wheezing is more commonly associated with bronchoconstriction or airway obstruction rather than opioid-induced respiratory depression. Naloxone is not indicated for wheezing unless there is concurrent opioid-induced respiratory depression.
D) Pulse oximeter reading of 89% on room air: While a pulse oximeter reading of 89% indicates hypoxemia, it may not be solely due to opioid-induced respiratory depression. Other factors, such as hypoventilation, ventilation-perfusion (V/Q) mismatch, or lung disease, could contribute to decreased oxygen saturation. Administering naloxone solely based on pulse oximetry readings may not address the underlying cause adequately. It is essential to assess the client comprehensively, considering clinical signs and symptoms along with objective data.
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