A med-surg patient is scheduled to receive docusate (Colace) at 9am. The night nurse advises the patient had two loose stools during her shift. The nurse would anticipate:
Administering half of the scheduled dose of Colace
Administering the scheduled dose of Colace
Inserting a rectal tube to prevent excoriation
Holding the scheduled dose of Colace and notifying the ordering physician
The Correct Answer is D
Choice A reason: Administering half of the scheduled dose of Colace is not the correct action for the nurse who is caring for a patient who had two loose stools during the night shift. Colace is the brand name of docusate, which is a stool softener that works by increasing the amount of water and fat in the stool, making it easier to pass. Colace is used to treat and prevent constipation, which is a condition of infrequent or hard bowel movements. Colace is not indicated for diarrhea, which is a condition of frequent and loose bowel movements. Administering half of the scheduled dose of Colace may not be enough to prevent constipation, and it may also worsen diarrhea by adding more water and fat to the stool.
Choice B reason: Administering the scheduled dose of Colace is not the correct action for the nurse who is caring for a patient who had two loose stools during the night shift. Colace is the brand name of docusate, which is a stool softener that works by increasing the amount of water and fat in the stool, making it easier to pass. Colace is used to treat and prevent constipation, which is a condition of infrequent or hard bowel movements. Colace is not indicated for diarrhea, which is a condition of frequent and loose bowel movements. Administering the scheduled dose of Colace may not be necessary to prevent constipation, and it may also worsen diarrhea by adding more water and fat to the stool.
Choice C reason: Inserting a rectal tube to prevent excoriation is not the correct action for the nurse who is caring for a patient who had two loose stools during the night shift. A rectal tube is a device that is inserted into the rectum and connected to a drainage bag, which collects the stool and prevents leakage and skin irritation. A rectal tube is used for patients who have fecal incontinence, which is the inability to control bowel movements. A rectal tube is not indicated for patients who have diarrhea, which is a condition of frequent and loose bowel movements. Inserting a rectal tube may not be effective to prevent excoriation, and it may also cause complications such as infection, bleeding, or perforation.
Choice D reason: Holding the scheduled dose of Colace and notifying the ordering physician is the correct action for the nurse who is caring for a patient who had two loose stools during the night shift. Colace is the brand name of docusate, which is a stool softener that works by increasing the amount of water and fat in the stool, making it easier to pass. Colace is used to treat and prevent constipation, which is a condition of infrequent or hard bowel movements. Colace is not indicated for diarrhea, which is a condition of frequent and loose bowel movements. Holding the scheduled dose of Colace may be appropriate to avoid further diarrhea, and notifying the ordering physician may be necessary to determine the cause and the treatment of diarrhea
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Ancef (ciprofloxacin) is not the correct answer for the nurse who anticipates administering a broad-spectrum antibiotic to a client diagnosed with a beta lactam resistant bacteria. Ancef is the brand name of cefazolin, which is a firstgeneration cephalosporin, a subclass of beta lactam antibiotics. Cefazolin is effective against gram-positive bacteria, but has limited activity against gram negative bacteria and anaerobes. Cefazolin is also susceptible to beta-lactamase enzymes, which are produced by some bacteria to degrade beta lactam antibiotics and confer resistance. The nurse should avoid using Ancef or any other beta lactam antibiotic for a client with a beta lactam resistant bacteria.
Choice B reason: Merrem (meropenem) is the correct answer for the nurse who anticipates administering a broad-spectrum antibiotic to a client diagnosed with a beta lactam resistant bacteria. Merrem is the brand name of meropenem, which is a carbapenem, a subclass of beta lactam antibiotics. Meropenem is effective against a wide range of bacteria, including gram-positive, gram negative, and anaerobic bacteria. Meropenem is also resistant to most beta-lactamase enzymes, except for metallo-beta-lactamase’s, which are rare and can be detected by laboratory tests. The nurse should consider using Merrem or another carbapenem for a client with a beta lactam resistant bacteria, unless they have a history of allergy or intolerance to beta lactam antibiotics .
Choice C reason: Flagyl (metronidazole) is not the correct answer for the nurse who anticipates administering a broad spectrum antibiotic to a client diagnosed with a beta lactam resistant bacteria. Flagyl is the brand name of metronidazole, which is a nitroimidazole antibiotic. Metronidazole is effective against anaerobic bacteria and some protozoa, but has no activity against aerobic bacteria. Metronidazole is not a beta lactam antibiotic, and it is not affected by beta-lactamase enzymes. However, metronidazole is not a broad spectrum antibiotic, and it is not suitable for treating infections caused by aerobic bacteria, which are more common than anaerobic bacteria. The nurse should use Flagyl only for specific indications, such as bacterial vaginosis, trichomoniasis, or Clostridioides difficile infection .
Choice D reason: Zosyn (piperacillin tazobactam) is not the correct answer for the nurse who anticipates administering a broad-spectrum antibiotic to a client diagnosed with a beta lactam resistant bacterium. Zosyn is the brand name of piperacillin tazobactam, which is a combination of penicillin, a subclass of beta lactam antibiotics, and a beta-lactamase inhibitor. Piperacillin is effective against some gram-positive and gram-negative bacteria, but it is susceptible to beta-lactamase enzymes. Tazobactam is a compound that binds to and inhibits some beta-lactamase enzymes, thereby protecting piperacillin from degradation and extending its spectrum of activity. However, piperacillin tazobactam is not effective against all types of beta-lactamase enzymes, especially those that are encoded by plasmids and can be transferred between bacteria. The nurse should not use Zosyn or any other beta lactam/beta-lactamase inhibitor combination for a client with a beta lactam resistant bacterium unless the specific type of beta-lactamase is known and susceptible to the inhibitor.
Correct Answer is D
Explanation
Choice A reason: This is incorrect. Aspirin can be used to relieve headache, but that is not its main function in this context. Aspirin is prescribed to patients who have had a heart attack to reduce the risk of another one.
Choice B reason: This is incorrect. Aspirin can be used to reduce fever, but that is not its main function in this context. Aspirin is prescribed to patients who have had a heart attack to reduce the risk of another one.
Choice C reason: This is incorrect. Aspirin does not act as an antiviral. It has no effect on viral infections. Aspirin is prescribed to patients who have had a heart attack to reduce the risk of another one.
Choice D reason: This is correct. Aspirin prevents further clot formation by inhibiting the activity of platelets, which are blood cells that help form clots. Clots can block the blood flow to the heart and cause a heart attack. Aspirin reduces the chance of this happening by making the blood less sticky.
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