A client has just received a high-dose fentanyl infusion for severe pain management. The nurse should monitor the client most closely for which adverse effect?

Rationale:

A. While it is important to review the patient’s medications to avoid drug interactions (e.g., with cholinergic or anticholinergic drugs), this is not the primary assessment to evaluate Tensilon’s effectiveness in diagnosing myasthenia gravis.

B. Respiratory status is critical to monitor due to the risk of respiratory compromise in myasthenia gravis or during a cholinergic crisis. However, prior to administering Tensilon for diagnostic purposes, the primary goal is to assess neuromuscular response, not respiratory function, although baseline respiratory assessment is part of overall safety.

C. Monitoring vital signs is necessary because edrophonium can cause bradycardia or hypotension, but these parameters do not measure the diagnostic effectiveness of the medication.

D. Tensilon works by temporarily inhibiting acetylcholinesterase, increasing acetylcholine at the neuromuscular junction. The diagnostic response is evaluated by observing improvement in muscle strength and endurance, typically in areas such as ptosis, facial muscles, or grip strength. Comparing pre- and post-administration muscle performance allows the nurse and provider to determine whether the patient has myasthenia gravis.

Rationale:

A. Clients in myxedema coma are often hypothermic, lethargic, or obtunded and may be unable to safely swallow. Oral intake is not reliable and can increase the risk of aspiration, so nutrition and fluids are administered intravenously until the patient is stabilized.

B. Myxedema coma can lead to respiratory depression, hypoventilation, and CO₂ retention. Supporting the airway and providing mechanical ventilation when needed is a priority intervention to maintain oxygenation and prevent respiratory failure.

C. Patients often present with hypotension, hyponatremia, and dehydration. IV fluids help restore intravascular volume, maintain perfusion, and correct electrolyte imbalances, which are essential for stabilizing cardiovascular function.

D. Myxedema coma can cause bradycardia, low cardiac output, and ECG changes. Continuous cardiac monitoring is critical because arrhythmias can develop rapidly and may be life-threatening.

E. Myxedema coma is associated with severe hypothermia, not hyperthermia. Active cooling would worsen the patient’s condition. Instead, passive rewarming with blankets and a warm environment is appropriate.

F. Thyroid hormone replacement is essential and life-saving in myxedema coma. IV administration is necessary because oral absorption may be unreliable due to decreased gastrointestinal motility or altered consciousness.