Nursing action question

[PinkCat8307]

I need some assistance to find out if I'm on the right track with my thinking on this question.

20 minutes after the client has recieved a preop injection of atropine and versed, the client tells you he must be allergic to the meds because his mouth is dray and his heart seems to be beating faster than normal. What is your best FIRST action?

a) document the findings as the only action

b) check the client's pulse and blood pressure

c) prepare to administer epinephrine and benadryl

d) explain to the client that these symptoms are normal responses to the medication

Ok, my thinking is that yes you would want to explain to the client that these symptoms are normal responses to the meds because this would be something that they might experience, However, I would think that anytime someone is complaining of these symptoms regardless of what meds they got you would want to check thier pulse and blood pressure before doing anything else. Am I on the right track with this thinking? Or am I overthinking and you would just want to do d.

Thanks for any extra brain power on this one. :)

[truern]

Remember to assess first.

I would check his HR to actually see what it is. Although it's more than likely the expected reaction to the drugs, what if it was alarmingly high?

[Daytonite, BSN, RN]

20 minutes after the client has recieved a preop injection of atropine and versed, the client tells you he must be allergic to the meds because his mouth is dray and his heart seems to be beating faster than normal. what is your best first action?

a) document the findings as the only action

b) check the client's pulse and blood pressure

c) prepare to administer epinephrine and benadryl

d) explain to the client that these symptoms are normal responses to the medication

my thinking on this is that the patient just made a complaint, so assess and gather data first to verify that there is tachycardia before documenting or explaining anything about these being normal responses.

[ShortStackRN]

I agree that you would check the HR FIRST...remember with these types of questions that it's not the RIGHT answer but the BEST answer...both B and D would be correct but you would want to check he HR FIRST...gotta love questions with multiple answers!! Keep using NCLEX practice questions and you'll get better at it...that's the only thing that's keeping my A's in MedSurg right now!

[Nurse523]

yes, b) check the client's pulse and blood pressure!

you do not want to make an assumption! it is correct that that medicate does product trachycardia and dry mouth but you want to assess to verify that these symptoms are from that medication and not something else. it will also proves that you as a nurse is accountable and you listen to your pts.