A client with irritable bowel syndrome (IBS) is receiving dicyclomine, an anticholinergic drug. Prior to administering the next dose, the practical nurse (PN) determines that the client's mucous membranes are dry, and the client reports having a dry mouth. Which action should the PN take
Check vital signs.
Notify the charge nurse.
Monitor hemoglobin.
Provide oral care.
Observe and report any ear drainage after removing the device.
The Correct Answer is D
Dry mucous membranes and a dry mouth are common side effects of anticholinergic drugs like dicyclomine. These medications block the action of acetylcholine, a neurotransmitter responsible for stimulating secretions in the body. As a result, the client may experience dryness in various parts of the body, including the mouth.
Providing oral care, such as offering the client sips of water or providing a moistening agent for the mouth, can help alleviate the discomfort caused by dryness and promote oral hygiene. It is an appropriate and immediate intervention for the client's current symptoms.
Incorrect:
A. Checking vital signs may not directly address the client's dry mouth, but it is a good practice to assess the client's overall condition.
B. Monitoring hemoglobin would not be necessary in this situation, as it does not directly relate to the client's dry mucous membranes.
C. Notifying the charge nurse may be appropriate if the client's symptoms worsen or if there are other concerning factors, but the priority action in this case is to provide oral care to address the client's discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Taking a rectal temperature requires a higher level of skill and carries a higher risk of injury compared to other methods, especially when dealing with a 2-year-old child with leukemia. Given the client's condition, it is important to minimize any potential harm or discomfort. Taking a tympanic temperature is a safer alternative that provides an accurate reading without the risk of injury.
B. Reminding the UAP to lubricate the thermometer before insertion is not appropriate because the PN should not encourage or support the UAP in performing a rectal temperature on a high-risk client. The focus should be on using a safer and less invasive method.
C. Instructing the UAP to report the results to the PN immediately is not necessary in this situation because the PN has already determined that taking a rectal temperature is not appropriate.
Instead, the PN should guide the UAP toward using the tympanic method.
D. Observing the UAP to ensure the thermometer is inserted correctly is not appropriate in this case because the PN has already determined that taking a rectal temperature is not the recommended course of action. It is more appropriate to redirect the UAP to use an alternative method.

Correct Answer is ["C","D","E","G"]
Explanation
The PN should double-check the following with a second nurse:
- The dose of insulin drawn up in the syringe: Double-checking the dose of insulin is essential to ensure the correct amount is being administered to the client.
- The insulin vial for color and clarity: Insulin should be clear and free of particles or discoloration. Checking the vial for any abnormalities ensures the integrity and quality of the insulin.
- The expiration date on the insulin vial: Insulin should not be used beyond its expiration date. Verifying the expiration date helps ensure that the insulin is still effective and safe for administration.
- The insulin concentration: Different concentrations of insulin are available, such as
U-100 and U-500. Double-checking the concentration ensures that the correct type of insulin is being administered.
It's important to note that the other options listed are not necessary for double-checking with a second nurse in this context:
- The sliding scale insulin lispro order: Sliding scale insulin is typically used to adjust insulin doses based on blood glucose levels. However, in this case, the given dose of 2 units of insulin lispro may be a specific prescription for the client's diabetes management and not related to the acute appendicitis.
- The type of insulin to be administered: The type of insulin, in this case, is specified as insulin lispro. Confirming the type of insulin is important, but it is not a part of the double-checking process since it is already specified.
- The history and physical with the diabetes diagnosis listed: The client's medical history and diabetes diagnosis are important aspects of their overall care but are not directly related to double-checking the administration of insulin.
- The site for insulin administration: The specific site for insulin administration may depend on the client's individual preference or medical condition, but it is not a part of the double-check process. The double-check is primarily focused on the accuracy of the medication itself.
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