During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic with increased oral secretions after receiving edrophonium IV. Vital signs are HR 55, BP 130/78, respiration 12 and saturation of 94%. What intervention should the nurse prepare to do?

Continue to monitor as this is a normal response to the medication

Administration of atropine

Place the patient in the trendelenburg position

Administer diphenhydramine (Benadryl) for the allergic reaction

Answer and Explanation

The Correct Answer is B

A) Continue to monitor as this is a normal response to the medication: The symptoms the patient is experiencing (cramping, diaphoresis, increased oral secretions) are not normal responses to the edrophonium test and suggest a cholinergic crisis rather than a simple reaction to the medication. A cholinergic crisis occurs when there is overmedication with cholinergic drugs, leading to excessive stimulation of the parasympathetic nervous system. While mild effects like slight nausea or dizziness can occur, cramping, diaphoresis, and increased oral secretions indicate toxicity, requiring immediate intervention.

B) Administration of atropine: The symptoms the patient is exhibiting—cramping, diaphoresis, and increased oral secretions—are indicative of cholinergic toxicity. Edrophonium, a cholinesterase inhibitor, is used in the Tensilon test to diagnose myasthenia gravis by temporarily improving muscle strength. However, in some cases, the patient may experience a cholinergic crisis from an overdose of the medication, resulting in excess acetylcholine at synapses, which overstimulates the parasympathetic nervous system. Atropine, an anticholinergic agent, blocks the effects of acetylcholine and is used to reverse these symptoms by reducing the excessive parasympathetic activity (e.g., reducing secretions and improving heart rate).

C) Place the patient in the Trendelenburg position: The Trendelenburg position (head down, feet up) is often used in cases of shock to help increase venous return to the heart. However, it is not appropriate for a cholinergic crisis. The patient’s symptoms are not due to hypotension or shock but are related to an overdose of edrophonium causing parasympathetic overstimulation.

D) Administer diphenhydramine (Benadryl) for the allergic reaction: The symptoms the patient is experiencing (cramping, diaphoresis, increased oral secretions) are not related to an allergic reaction. Diphenhydramine (Benadryl) is an antihistamine used for allergic reactions, such as urticaria or anaphylaxis, but it does not treat cholinergic toxicity.

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Correct Answer is C

Explanation

A) Normal saline 1 liter to client who is dehydrated:
Administering normal saline to a dehydrated client is an important task, as it helps to restore fluid balance and improve circulatory volume. However, while rehydration is critical, it is not an immediate, life-threatening priority compared to other interventions. The nurse should begin this infusion after addressing more urgent needs such as severe chest pain, which could indicate a cardiac emergency.

B) Morphine sulfate 4mg intravenously (IV) now for the client experiencing incisional pain:
Morphine is a potent analgesic, and relieving pain for postoperative patients is essential for comfort and recovery. However, incisional pain, although important to address, is not life-threatening in this scenario. The client with chest pain should be prioritized because chest pain could indicate a myocardial infarction (MI) or other serious cardiac event that requires immediate intervention.

C) Nitroglycerin (Nitrostat) 0.4 mg sublingually (SL) stat for the client experiencing crushing chest pain:
Crushing chest pain is a classic symptom of acute myocardial infarction (MI), a life-threatening condition that requires immediate intervention. Nitroglycerin is used to relieve chest pain associated with angina or MI by dilating the coronary arteries and improving blood flow to the heart. In this case, chest pain is the most critical symptom, and immediate treatment is necessary to reduce the risk of further cardiac damage or complications.

D) Lorazepam 2 mg IV now for the client who is anxious and restless:
While lorazepam is an effective medication for anxiety and restlessness, it is not the most urgent medication in this case. The client’s anxiety should be addressed, but it does not pose an immediate threat to life. Anxiety can generally be managed after more acute, life-threatening conditions (such as chest pain) are stabilized.

A. Pneumococcal vaccine B. Influenza vaccine C. COVID - 19 vaccine D. HIB vaccine E. -Rotavirus vaccine

Correct Answer is ["A","B","C"]

Explanation

A. Pneumococcal vaccine:

The pneumococcal vaccine is recommended for older adults to protect against Streptococcus pneumoniae, a common cause of pneumonia and other invasive diseases. Individuals over 65 years of age are at increased risk for pneumococcal infections, making this vaccine essential for their health.

B. Influenza vaccine:

The influenza vaccine is recommended annually for older adults, as they are at high risk for severe complications from influenza due to age-related immune system decline. Preventing influenza reduces the risk of secondary infections, such as pneumonia.

C. COVID-19 vaccine:

COVID-19 vaccines are strongly recommended for older adults because they are at higher risk for severe illness and complications from COVID-19. Staying up to date with booster doses further reduces the risk of hospitalization and death.

D. HIB vaccine:

The Haemophilus influenzae type b (HIB) vaccine is not routinely recommended for adults unless they have specific medical conditions, such as asplenia or immunodeficiencies. This vaccine is primarily targeted for infants and young children.

E. Rotavirus vaccine:

The rotavirus vaccine is not recommended for adults. It is specifically designed to prevent rotavirus gastroenteritis in infants and young children. There is no clinical indication for its use in the older adult population.

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Naxlex Comprehensive Predictor Exams

A nurse receives the following medication orders while caring for multiple clients. Which medication should the nurse plan to administer first?

Correct Answer is C

Explanation

Correct Answer is ["A","B","C"]

Explanation

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A nurse is assessing a client who has been recently diagnosed with Bell's palsy. Which of the following findings should the nurse expect? [Select all that apply.]

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