A client has received a dose of atropine to counteract the effects of a cholinergic medication prior to having surgery
On the way to the operating room (OR), the client complains of a sudden feeling of warmth. The client's skin is flushed, warm, and dry. Which nursing action is the most appropriate?
1. Assessing the vital signs and advising the OR that surgery must be delayed for 1 hour.
2. Assessing the client's mental status and vital signs. If normal, document finding and proceed to operating room.
3. Notifying the surgeon of the client's vital signs.
4. Explaining the side effects of atropine to the client.
Correct Answer: 2
Rationale 1: Delaying the surgery would be inappropriate given the timing and half-life of atropine.
Rationale 2: Assess the client's mental status and vital signs. If normal, document the finding and proceed to operating room and report the finding to the surgeon and anesthesiologist.
Rationale 3: Notifying the surgeon of the client's vital signs would only be necessary if the client's vital signs were abnormal. The symptoms described are common for the medication given.
Rationale 4: Explaining the side effects of atropine to the client is appropriate, but not the most appropriate, as documentation of the vital signs would be more critical.
Global Rationale: Assess the client's mental status and vital signs. If normal, document the finding and proceed to operating room and report the finding to the surgeon and anesthesiologist. Delaying the surgery would be inappropriate given the timing and half-life of atropine. Notifying the surgeon of the client's vital signs would only be necessary if the client's vital signs were abnormal. The symptoms described are common for the medication given. Explaining the side effects of atropine to the client is appropriate, but not the most appropriate, as documentation of the vital signs would be more critical.
You might also like to view...
The family of a newborn has just been told their infant has tetralogy of Fallot. The family does not seem to understand the explanation given by the physician. What statement by the nurse is best?
1. "With this defect, not enough of the blood circulates through the lungs, leading to a lack of oxygen in the baby's body." 2. "The baby's aorta has a narrowing in a section near the heart that makes the left side of the heart work harder." 3. "The blood vessels that attach to the ventricles of the heart are positioned on the wrong sides of the heart." 4. "Your baby's heart doesn't circulate blood well because the left ventricle is smaller and thinner than normal."
The nurse is caring for a client who is experiencing hyperthermia. Which intervention is appropriate for this client?
A) Applying warm blankets B) Administering a prescribed antipyretic medication C) Keeping limbs close to the body D) Covering the scalp with a hat
Which of the following symptoms should a nurse monitor for to determine whether the condition of a client with conjunctivitis is severe?
A) Excessive tearing B) Swelling and pain C) Burning or itching D) Enlarged lymph nodes in the neck or throat area
Which of the following are some of the qualities found in a team player? (Select all that apply.)
a. Competence b. Dependability c. Enthusiasm d. Being on time e. Being friendly