The nurse provides a client with a dose of the beta-selective adrenergic agonist isoproterenol. Which assessment finding indicates the medication is effective?
Constricted pupils
Warm, dry skin
Increased heart rate
Decreased urine output
The Correct Answer is C
A. Constricted pupils are not an expected response to isoproterenol, which generally causes dilation of the pupils due to sympathetic stimulation.
B. Warm, dry skin is not a direct indicator of the effectiveness of isoproterenol; it could result from various factors unrelated to the medication's action.
C. Increased heart rate indicates that isoproterenol, which is a beta-agonist, is effectively stimulating the beta-adrenergic receptors, leading to increased cardiac output and heart rate.
D. Decreased urine output is not a sign of effectiveness and could indicate adverse effects such as reduced renal perfusion.
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Correct Answer is B
Explanation
A. Performing a blood sugar analysis is important, but the immediate symptoms indicate hypoglycemia, and rapid treatment is necessary before confirming blood sugar levels.
B. Having the client drink a glass of orange juice provides a quick source of glucose to counteract hypoglycemia, which is the most appropriate initial response to address the client's symptoms.
C. Administering 1 ampule of 50% dextrose intravenously is an appropriate intervention for severe hypoglycemia but is not the initial step for a client who can still take oral carbohydrates.
D. Administering insulin would worsen the client's condition by lowering blood sugar levels further, which is not indicated in this scenario.
Correct Answer is ["A","B","C"]
Explanation
A. Auscultating bowel sounds is important because anticholinergic agents can decrease gastrointestinal motility, leading to reduced bowel sounds and potential constipation.
B. Monitoring urine output is crucial as anticholinergics can cause urinary retention, and assessing output helps identify any adverse effects on bladder function.
C. Monitoring heart rate is necessary since anticholinergic agents can cause tachycardia as a side effect, making it important to assess the client’s cardiovascular status.
D. Administering an antidiarrheal agent is not typically indicated, as anticholinergic agents often cause constipation rather than diarrhea.
E. Assessing deep tendon reflexes is not directly relevant to the effects of anticholinergic medications and is not typically prioritized in this context.