A client taking a chemical stimulant laxative and medications for heart failure and osteoarthritis calls the clinic and reports, “I’m just not feeling right.” What is the priority question the nurse should ask this client?
Amount of fluid intake.
Timing of medication administration.
Previous effectiveness of laxatives.
The amount of fiber intake.
The Correct Answer is A
The nurse should ask this question because the client is taking a chemical stimulant laxative, which can cause dehydration and electrolyte imbalance, especially in combination with medications for heart failure and osteoarthritis that may also affect fluid and electrolyte balance. The nurse should assess the client’s hydration status and risk of hypovolemia or hypotension.
Choice B. Timing of medication administration is wrong because it is not the priority question in this situation.
The nurse should ask this question later to determine if the client is taking the medications as prescribed and if there are any drug interactions or adverse effects.
Choice C. Previous effectiveness of laxatives is wrong because it is not relevant to the client’s current condition.
The nurse should ask this question later to evaluate the client’s bowel habits and history of constipation.
Choice D. The amount of fiber intake is wrong because it is not the priority question in this situation.
The nurse should ask this question later to educate the client about dietary measures to prevent constipation and promote bowel health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Diaphoresis means excessive sweating, which is one of the symptoms of hypoglycemia. Hypoglycemia occurs when the blood sugar level is lower than the normal range, which can cause dizziness, confusion, weakness, hunger, and other signs.
Choice B is wrong because flushing of the face is not a symptom of hypoglycemia.
Flushing can be caused by other conditions, such as fever, allergic reactions, or rosacea.
Choice C is wrong because fruity breath is a symptom of hyperglycemia, not hypoglycemia.
Hyperglycemia means high blood sugar level, which can cause the body to produce ketones that give the breath a fruity odor.
Choice D is wrong because unpredictable behaviors are not a specific symptom of hypoglycemia.
However, hypoglycemia can cause confusion, irritability, or anxiety, which may affect the behavior of some people.
The normal range of blood sugar level for most people is between 70 and 130 mg/dL (3.9 and 7.2 mmol/L) before meals and less than 180 mg/dL (10 mmol/L) after meals.
However, this may vary depending on the individual and the type of diabetes.
It is important to monitor the blood sugar level regularly and treat hypoglycemia promptly by eating or drinking a simple sugar source.
Correct Answer is C
Explanation
The correct answer is c. The importance of consuming adequate amounts of water.
Rationale for Choice A:
- Statement:The need to monitor for systemic side effects.
- Rationale:It's not accurate to prioritize monitoring for systemic side effects when teaching a patient about psyllium (Metamucil).Psyllium is a bulk-forming laxative that primarily acts within the gastrointestinal tract,and systemic side effects are rare.While it's essential to be aware of potential side effects,focusing on them during initial teaching might cause unnecessary anxiety.
Rationale for Choice B:
- Statement:The need to use the dry form of Metamucil to prevent cramping.
- Rationale:This statement is incorrect.It's generally recommended to mix psyllium with water or another liquid before ingestion.Consuming the dry form can increase the risk of choking and might not adequately hydrate stool.
Rationale for Choice C:
- Statement:The importance of consuming adequate amounts of water.
- Rationale:This is the most crucial information to emphasize when teaching about psyllium.Psyllium works by absorbing water and forming a bulky gel that softens stool and promotes bowel movements.Without sufficient water intake,psyllium can cause constipation to worsen or lead to intestinal obstruction.
Rationale for Choice D:
- Statement:The onset of action of 30 to 60 minutes after administration.
- Rationale:This statement is inaccurate.Psyllium is not a fast-acting laxative.It typically takes 12-72 hours to produce a bowel movement.Informing patients about the expected time frame for results is essential to manage expectations and prevent unnecessary medication overuse.
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