Nokea
A nurse is caring for a client who has been prescribed belladonna for the treatment of prolonged diarrhea. Which of the following nursing interventions should the nurse perform before administering the drug?
- A. Check stools of the client.
- B. Monitor for abdominal pain.
- C. Assess weight of the client.
- D. Monitor vital signs every 2 hours.
Correct Answer: C
Rationale: The nurse should assess the client's weight when caring for this client with prolonged diarrhea.
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A client has a nursing diagnosis of Impaired Comfort related to xerostomia from the daily administration of a cholinergic blocking drug. When assessing the client, the nurse would be alert for which of the following?
- A. Dysphagia
- B. Tooth decay
- C. Gingivitis
- D. Impeded speech
- E. Gingival hyperplasia
Correct Answer: A,D
Rationale: Dry mouth caused by daily use of cholinergic blocking drugs can result in dysphagia and impeded, difficult-to-understand speech. Tooth decay, gingivitis, and gingival hyperplasia are not associated with dry mouth.
The nurse instructs the client and family about possible visual and mental adverse reactions that can occur. Which of the following would the nurse include in the teaching to reduce the client's risk for injury?
- A. Removing throw rugs
- B. Moving furniture against the wall
- C. Making sure floors are dry
- D. Avoiding having the floors waxed
- E. Removing electrical cords from walkways
Correct Answer: A,B,C,D,E
Rationale: Objects or situations that may cause falls, such as throw rugs, electrical cords, footstools, furniture, and wet or newly waxed floors, are removed or avoided whenever possible.
A nurse is caring for a client receiving cholinergic blocking drug therapy. The client complains of a cotton-mouth feeling. Which of the following would be most appropriate?
- A. Inspect the throat for signs of an infection.
- B. Suggest the client avoid ingesting water before taking the drug.
- C. Check the oral cavity daily for soreness or ulcerations.
- D. Suggest the client avoid the use of ice or cold beverages.
Correct Answer: C
Rationale: The nurse should check the oral cavity daily for soreness or ulcerations when caring for a client with severe mouth dryness.
The nurse should monitor clients taking which of the following medications closely for decreased efficacy if a cholinergic blocking drug is initiated.
- A. Fluconazole (Diflucan)
- B. Meperidine (Demerol)
- C. Haloperidol (Haldol)
- D. Amitriptyline (Elavil)
- E. Digoxin (Lanoxin)
Correct Answer: A,C
Rationale: The nurse should monitor clients taking fluconazole (Diflucan) and haloperidol (Haldol) closely for decreased efficacy if a cholinergic blocking drug is initiated.
A nurse is administering a cholinergic blocking drug preoperatively to a client. What intervention should the nurse perform after administering the drug to the client?
- A. Provide cold milk to the client.
- B. Raise the side rails of the bed.
- C. Tell the client to lie completely flat in bed.
- D. Provide frequent sips of water.
Correct Answer: B
Rationale: The nurse should raise the side rails of the client's bed after administration of the drug.