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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A continuous seizure state in which seizures occur in rapid succession:
This describes status epilepticus, a medical emergency characterized by prolonged or continuous seizures. It is not related to the concept of an aura.
B. A sensory warning that a seizure is imminent:
This is the correct answer. An aura is a subjective sensation or symptom that acts as a warning sign that a seizure is about to occur. Auras can vary widely among individuals and may include visual, auditory, olfactory, or other sensory experiences.
C. A period of sleepiness following the seizure during which arousal is difficult:
This describes the postictal state, which occurs after a seizure. During this period, the individual may experience confusion, drowsiness, or difficulty arousing from sleep. It is not specifically related to the concept of an aura.
D. A brief loss of consciousness accompanied by staring:
This describes an absence seizure, characterized by a brief loss of awareness and a blank stare. Absence seizures typically do not have an aura preceding them.
Correct Answer is ["10"]
Explanation
To calculate the dose of valproic acid oral solution, the nurse should use the following formula:
Dose (mL) = Ordered dose (mg) / Concentration (mg/mL) x Volume (mL)
Plugging in the values from the question, we get:
Dose (mL) = 500 mg / (250 mg / 5 mL) x 5 mL
Simplifying, we get:
Dose (mL) = 500 mg / 50 mg x 5 mL
Dose (mL) = 10 mL
Therefore, the nurse should administer 10 of valproic acid oral solution to the patient.
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