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 B
Explanation
This statement suggests that the client has found sources of emotional support and is relying on them to cope with the challenges posed by his prognosis. Acceptance of a prognosis often involves coming to terms with the reality of the situation and finding ways to manage the emotional and practical aspects of it. By acknowledging the support he has received from his faith and family, the client demonstrates a willingness to lean on these resources for strength and comfort.
The other statements do not necessarily reflect acceptance of the prognosis:
A. "I think I had this disease for a long time, but the doctor did not find it." This statement implies a sense of disbelief or frustration with the delay in diagnosing the disease, rather than acceptance of the prognosis itself.
C. "I understand this is a disease that occurs mostly in older men." While this statement shows some awareness of the disease, it does not necessarily indicate acceptance. It may simply reflect an understanding of the demographics of prostate cancer without addressing the client's personal feelings or coping mechanisms.
D. "I do not have any use for those who say this disease is going to win." This statement may indicate resistance or defiance towards the negative outlook associated with the disease. It suggests a desire to maintain a positive attitude but does not necessarily reflect a full acceptance of the prognosis and its implications.
Correct Answer is B
Explanation
Stomatitis refers to the inflammation of the mouth and oral mucosa, which can cause pain and difficulty swallowing. In the context of a client receiving chemotherapy, stomatitis is a common side effect that can occur due to the effects of chemotherapy on rapidly dividing cells, including those in the oral cavity. When a client develops stomatitis, it is important for the practical nurse (PN) to obtain information about the client's ability to swallow during a focused assessment. This is because stomatitis can significantly impact a client's ability to eat and drink comfortably, which can lead to dehydration and malnutrition. Assessing the client's ability to swallow helps determine the extent of the issue and guides appropriate interventions and support.
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