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 C
Explanation
Choice A reason: This is incorrect. Miosis is the constriction of the pupils, which can also be caused by morphine, but it is not a life-threatening side effect. Miosis occurs because morphine stimulates the parasympathetic nervous system, which controls the muscles that constrict the pupils¹.
Choice B reason: This is incorrect. Sedation is the state of being calm, relaxed, and sleepy, which can also be caused by morphine, but it is not a life-threatening side effect. Sedation occurs because morphine depresses the central nervous system, which reduces the activity of the brain and the body.
Choice C reason: This is correct. Respiratory depression is the slowing down of breathing, which can be a life-threatening side effect of morphine. Respiratory depression occurs because morphine depresses the respiratory center in the brainstem, which regulates the rate and depth of breathing. If the breathing becomes too slow or shallow, the patient may not get enough oxygen and may lose consciousness or die.
Choice D reason: This is incorrect. Euphoria is the feeling of intense happiness, pleasure, or wellbeing, which can also be caused by morphine, but it is not a life-threatening side effect. Euphoria occurs because morphine stimulates the reward system in the brain, which releases dopamine, a neurotransmitter that causes positive emotions.
Correct Answer is D
Explanation
Choice A reason: Allergy is an immune mediated reaction to a substance that causes symptoms such as rash, itching, swelling, or anaphylaxis. It is not related to the duration or effectiveness of the medication. The patient does not report any signs of allergy to the opioids.
Choice B reason: Addiction is a chronic and compulsive disorder that involves seeking and using a substance despite harmful consequences. It is characterized by loss of control, craving, and impaired functioning. The patient does not show any signs of addiction to the opioids, such as increasing the dose, obtaining the medication illegally, or neglecting other responsibilities.
Choice C reason: Withdrawal is a syndrome that occurs when a substance is abruptly discontinued or reduced after prolonged use. It causes physical and psychological symptoms such as anxiety, agitation, sweating, nausea, or tremors. The patient does not experience any signs of withdrawal from the opioids, as they are still taking the medication as prescribed.
Choice D reason: Tolerance is a phenomenon that occurs when a substance loses its effectiveness over time due to repeated exposure. It requires higher doses or more frequent administration to achieve the same effect. The patient reports a sign of tolerance to the opioids, as they feel that the medication does not work as well anymore. The nurse should assess the patient's pain level, monitor the opioid dose, and consult with the prescriber about possible adjustments or alternatives.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today