A client with myasthenia gravis receives a new prescription for pyridostigmine. Which information should the nurse obtain to prior to administering the medication?
Recent oral intake.
Difficulty with urination.
Trouble sleeping.
Unexplained weight loss.
The Correct Answer is A
Rationale:
A. Pyridostigmine is most effective when taken before meals to improve muscle strength for swallowing. Knowing the client's recent oral intake helps in timing the medication appropriately.
B. Difficulty with urination is not directly related to pyridostigmine use.
C. Trouble sleeping is not typically associated with pyridostigmine.
D. Unexplained weight loss may be related to myasthenia gravis but is not directly relevant to the immediate administration of pyridostigmine.
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Correct Answer is C
Explanation
Rationale:
A. Pneumonia typically presents with fever, productive cough, and lung consolidation, not just wheezing and low oxygen saturation.
B. Pneumothorax usually causes sudden sharp chest pain and decreased breath sounds on the affected side, rather than wheezing and prolonged expiration.
C. Asthma is characterized by wheezing, prolonged expiration, and low oxygen saturation due to bronchoconstriction and inflammation. The client's symptoms are consistent with an asthma exacerbation.
D. Bronchitis presents with a productive cough and sometimes wheezing but does not typically cause such severe hypoxemia or a pronounced increase in respiratory rate as seen here.
Correct Answer is D
Explanation
Rationale:
A. Urinary output is important but not as critical as identifying the potential source of infection.
B. A 24-hour medication history is useful but secondary to identifying an acute infection.
C. The amount of serous drainage provides information on wound healing but does not confirm infection.
D. Increased confusion in an older adult, especially with a wound present, raises concern for infection, possibly sepsis. A WBC count can help identify infection and guide further treatment.