The nurse is caring for a patient taking a cholinergic agent. When auscultating lung sounds, the nurse notes inspiratory and expiratory wheezing bilaterally. The best action for the nurse to take would be to:
withhold the next dose and notify the physician
give the next dose
assess heart rate
assess blood pressure
The Correct Answer is A
A. Withhold the next dose and notify the physician:
Withholding the next dose of the cholinergic agent is the appropriate immediate action because the presence of inspiratory and expiratory wheezing bilaterally suggests bronchoconstriction or bronchospasm, which can be a serious adverse reaction to the medication. Notifying the physician promptly allows for further assessment and management of the patient's respiratory symptoms. The physician may need to adjust the medication regimen, order diagnostic tests, or provide treatment for bronchoconstriction.
B. Give the next dose:
Administering the next dose of the cholinergic agent could worsen the patient's respiratory symptoms and exacerbate bronchoconstriction. This action is contraindicated in the presence of wheezing, as it may further compromise the patient's respiratory function.
C. Assess heart rate:
While assessing heart rate is an important aspect of patient assessment, it is not the priority in this scenario. The priority is to address the respiratory distress and potential bronchoconstriction associated with the cholinergic agent. Wheezing is a respiratory symptom that suggests airway obstruction, and immediate intervention is necessary to ensure adequate oxygenation and ventilation.
D. Assess blood pressure:
Similarly, while assessing blood pressure is important in patient care, it is not the priority in this situation. The priority is to address the respiratory distress and potential bronchoconstriction associated with the cholinergic agent. Wheezing indicates respiratory compromise, and prompt action is required to prevent further respiratory deterioration.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "These drugs inhibit the action of acetylcholine":
This response is accurate. Anticholinergic medications work by blocking the action of acetylcholine, a neurotransmitter involved in various functions in the body, including muscle control. In Parkinson's disease, there is an imbalance between dopamine and acetylcholine, leading to motor symptoms such as tremors and rigidity. By inhibiting the action of acetylcholine, anticholinergic drugs help rebalance neurotransmitter activity and alleviate some of the motor symptoms associated with Parkinson's disease.
B. "These drugs help you urinate":
This statement is not directly related to the use of anticholinergic medications in Parkinson's disease. While some anticholinergic drugs can indeed relax the smooth muscle of the bladder and improve urinary symptoms, this is not the primary indication for their use in Parkinson's disease.
C. "These drugs will decrease your eye pressure":
While anticholinergic medications can be used to dilate the pupils and decrease intraocular pressure, this is not typically the reason for their use in Parkinson's disease. While some anticholinergic medications may have ocular effects, they are primarily used to address motor symptoms associated with Parkinson's disease.
D. "These drugs will assist in lowering your heart rate":
While some anticholinergic medications may have effects on heart rate by blocking parasympathetic nervous system activity, this is not the primary indication for their use in Parkinson's disease. The focus of anticholinergic therapy in Parkinson's disease is primarily on addressing motor symptoms rather than cardiovascular effects.
Correct Answer is C
Explanation
A. Diarrhea:
Diarrhea is not a common side effect of phenytoin. While gastrointestinal disturbances such as nausea, vomiting, and constipation may occur, diarrhea is less common. Therefore, it is not a primary adverse effect that the nurse should instruct the client to monitor and report.
B. Wrist pain:
Wrist pain is not a common side effect of phenytoin. Side effects related to musculoskeletal issues such as joint pain, muscle weakness, or muscle twitching can occur, but wrist pain specifically is not commonly associated with phenytoin use. Therefore, it is not a primary adverse effect that the nurse should instruct the client to monitor and report.
C. Skin rash:
Skin rash is a potential adverse effect of phenytoin that should be monitored and reported. Phenytoin can cause various skin reactions, including a mild rash or more severe reactions such as Stevens-Johnson syndrome or toxic epidermal necrolysis. Therefore, the nurse should instruct the client to promptly report any signs of skin rash or other skin changes.
D. Metallic taste:
Metallic taste is a common side effect of phenytoin. While it is not usually a serious adverse effect, it can be bothersome for some individuals. Therefore, the nurse should instruct the client to monitor for this side effect and report it if it occurs persistently or becomes bothersome.
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