A nurse is caring for a client who received neostigmine 1 hr ago and is experiencing a muscarinic response.
Which of the following manifestations should the nurse expect?

Occipital headache.

Fever.

Excessive salivation.

Myoclonic seizure.

Answer and Explanation

The Correct Answer is C

Neostigmine is an anticholinesterase inhibitor that indirectly stimulates both nicotinic and muscarinic receptors by interfering with the breakdown of acetylcholine.

Stimulation of muscarinic receptors can lead to increased salivation.

Choice A is wrong because an occipital headache is not a manifestation of a muscarinic response to neostigmine.

Choice B is wrong because fever is not a manifestation of a muscarinic response to neostigmine.

Choice D is wrong because a myoclonic seizure is not a manifestation of a muscarinic response to neostigmine.

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Correct Answer is A

Explanation

The nurse should monitor the client for hearing loss because it is a potential adverse effect of erythromycin.

Choice B is wrong because a high-fiber diet to prevent constipation is not mentioned as a necessary action when administering erythromycin lactobionate IV bolus.

Choice C is wrong because erythromycin lactobionate IV bolus should not be administered over 10 min; bolus injection (IV push) is contraindicated.

Choice D is wrong because erythromycin lactobionate should not be reconstituted with a 5% dextrose solution; it should be reconstituted with sterile water for injection.

A. The client had chemotherapy 12 hr before the medication was administered. B. The medication vial sat at room temperature for 2 hr before it was administered. C. The client's absolute neutrophil count was 2,500/mm³ before the medication was administered. D. The nurse flushed the client's IV line with dextrose 5% in water before and after the medication was administered.

Correct Answer is A

Explanation

Choice A rationale: Administering filgrastim after chemotherapy is a standard practice to boost white blood cell count. However, filgrastim should not be given within 24 hours before or after chemotherapy, as it can affect the efficacy and increase the risk of side effects. Administering the medication 12 hours after chemotherapy falls within this contraindicated window, necessitating an incident report.

Choice B rationale: Filgrastim can be stored at room temperature for short periods, and 2 hours is generally within acceptable limits for stability.

Choice C rationale: An absolute neutrophil count of 2,500/mm³ is within the normal range, and there is no contraindication for administering filgrastim.

Choice D rationale: Flushing the client's IV line with dextrose 5% in water before and after administering filgrastim is not appropriate, as this medication is typically administered with saline solution. Using an incorrect flushing solution could affect the medication's efficacy or compatibility, necessitating an incident report.

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A nurse is caring for a client who received neostigmine 1 hr ago and is experiencing a muscarinic response. Which of the following manifestations should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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A nurse is caring for a client who received neostigmine 1 hr ago and is experiencing a muscarinic response.
Which of the following manifestations should the nurse expect?