A client received psyllium this morning. Which assessment finding indicates a therapeutic effect of the medication?

1 x soft bowel movement

Gastric pH 2 (Normal pH: 1-4)

500 ml of urine output

Blood glucose: 95 (Normal Fasting Blood Glucose: 60-120)

Answer and Explanation

The Correct Answer is A

A) 1 x soft bowel movement: This is the correct answer. Psyllium is a bulk-forming laxative that helps to relieve constipation by absorbing water into the stool, making it easier to pass. A therapeutic effect of psyllium would be the client experiencing a soft bowel movement, indicating the medication has helped to regulate the client's bowel movements and relieve constipation.

B) Gastric pH 2 (Normal pH: 1-4): While this is a normal gastric pH range, it is not related to the therapeutic effect of psyllium. Psyllium works in the gastrointestinal tract to promote bowel regularity, not to alter gastric pH. The pH measurement of gastric contents is not a relevant indicator of the medication's effectiveness.

C) 500 ml of urine output: This finding is not related to the therapeutic effect of psyllium. Psyllium is intended to address bowel function, not urine output. Adequate urine output should be monitored, but it is not the expected outcome for a patient taking psyllium.

D) Blood glucose: 95 (Normal Fasting Blood Glucose: 60-120): While a normal blood glucose level is important, it is not relevant to the action of psyllium. Psyllium does not have a direct effect on blood glucose levels, so a normal blood glucose result is not indicative of a therapeutic effect of the medication.

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Correct Answer is B

Explanation

A) Right dose: The right dose was administered. The order specifies 1000 mg of
acetaminophen, and the nurse gave 1000 mg. Therefore, the right dose was given, and this is not the issue in this situation.

B) Right route: The right route was not followed in this situation. The order specifies that acetaminophen should be administered IV, but the nurse administered the medication PO. The route of administration is crucial for ensuring the medication is delivered in the appropriate manner for the intended therapeutic effect. By giving the medication orally instead of intravenously, the nurse deviated from the prescribed route, which is a violation of the "right route."

C) Right reason: The right reason was followed because acetaminophen is commonly given for pain or fever management, and no information suggests the wrong reason for administering the drug. The nurse's action doesn’t indicate a mistake in the reasoning for giving the medication.

D) Right time: The right time is not affected here, as the nurse did administer the acetaminophen at the scheduled time. The issue is with the route, not the timing.

A. The nurse demonstrates to the client how to perform a blood glucose test using the glucometer. B. The nurse formulates a goal of "The client will have a blood sugar between 120-180 for the entire shift C. The nurse administers the ordered subcutaneous injection of insulin to the client. D. The nurse uses a glucometer to check the client's blood glucose level via a finger stick.

Correct Answer is B

Explanation

This action reflects the planning phase of the nursing process, where the nurse sets measurable and achievable goals based on the client's assessment data.

Here’s how the other options fall into different phases:

A. Demonstrating how to perform a blood glucose test = Implementation (teaching/intervention).

C. Administering insulin = Implementation (carrying out an intervention).

D. Checking blood glucose level = Assessment (gathering data).

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A client received psyllium this morning. Which assessment finding indicates a therapeutic effect of the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client is to receive acetaminophen 1000 mg IV Q6 hours. Today, the nurse administered acetaminophen 1000 mg PO. Which of the 9 rights was not followed in this situation?

Correct Answer is B

Explanation

A nurse assesses the client and determines the client is at risk for unstable blood glucose. Which activity best reflects the planning phase of the nursing process?

Correct Answer is B

Explanation

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