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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Related Questions
Correct Answer is B
Explanation
A. Decreased pedal pulses:
Decreased pedal pulses are not typically associated with increased intracranial pressure. Instead, they may indicate peripheral vascular disease or reduced perfusion to the lower extremities. Monitoring peripheral pulses is important for assessing circulation but is not directly related to intracranial pressure changes.
B. Hypertension:
Hypertension can be a manifestation of increased intracranial pressure. The body may respond to elevated intracranial pressure by increasing blood pressure to maintain cerebral perfusion pressure. However, hypertension alone is not specific to increased ICP and can have various causes.
C. Peripheral edema:
Peripheral edema is not a typical manifestation of increased intracranial pressure. It may occur in conditions such as heart failure or renal dysfunction but is not directly related to intracranial pressure changes following a craniotomy.
D. Diarrhea:
Diarrhea is not a common manifestation of increased intracranial pressure. Increased ICP is more likely to manifest with symptoms such as headache, nausea, vomiting, altered level of consciousness, and focal neurological deficits.
Correct Answer is ["A","B","D"]
Explanation
A. Provide a suction setup at the bedside:
This is a relevant intervention as it ensures that suction equipment is readily available in case the client experiences excessive secretions or vomiting during or after a seizure. It helps maintain a clear airway and prevent aspiration.
B. Elevate the side rails when in bed:
Elevating the side rails can help ensure the client's safety during a seizure by preventing falls from the bed. It is a preventive measure to minimize the risk of injury.
C. Place a bite stick at the bedside:
Placing a bite stick at the bedside is not a recommended intervention. Bite sticks can potentially injure the patient's teeth or mouth during a seizure and are generally not recommended in current practice.
D. Keep an oxygen setup at the bedside:
This is an appropriate intervention as it ensures that oxygen is readily available in case the client experiences respiratory distress or hypoxia during or after a seizure. Oxygen therapy may be needed to support respiratory function.
E. Furnish restraints at the bedside:
Furnishing restraints at the bedside is not a recommended intervention for managing seizures. Restraints should only be used in exceptional circumstances when the client's safety or the safety of others is at risk and should be applied according to institutional policies and legal regulations.
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