A nurse is teaching a client who is taking medication before bedtime. The nurse should include the following instructions:
Do not take the medication before bedtime.
Take the medication with a full glass of water.
This medication must be taken on an empty stomach.
Expect abdominal pain with this medication.
The Correct Answer is B
Choice A Reason:
“Do not take the medication before bedtime” is incorrect because the timing of medication administration depends on the specific medication and its intended effects. Some medications are specifically prescribed to be taken at bedtime to help with sleep or to reduce side effects that might occur during the day.
Choice B Reason:
“Take the medication with a full glass of water” is correct because many medications require adequate hydration to ensure proper absorption and to prevent irritation of the esophagus and stomach. Taking medication with a full glass of water helps to ensure that the medication reaches the stomach quickly and reduces the risk of esophageal irritation or damage.
Choice C Reason:
“This medication must be taken on an empty stomach” is incorrect unless the specific medication requires it. Some medications are better absorbed on an empty stomach, but this is not a universal rule and depends on the medication’s formulation and intended use.
Choice D Reason:
“Expect abdominal pain with this medication” is incorrect because not all medications cause abdominal pain. If a medication is known to cause abdominal pain, the nurse should provide additional instructions on how to manage this side effect or discuss alternative medications with the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Applying compression stockings is a key prophylactic intervention to prevent complications of immobility, such as deep vein thrombosis (DVT) and venous thromboembolism (VTE). Compression stockings help improve blood circulation in the legs by applying graduated pressure, which reduces the risk of blood clots forming in the deep veins. This is particularly important for immobile patients who are at higher risk of developing DVT due to prolonged periods of inactivity.
Choice B reason: Raising all side rails is primarily a safety measure to prevent falls and does not directly address the complications of immobility. While it is important for patient safety, it does not have a significant impact on preventing issues like DVT, pressure ulcers, or muscle atrophy. Therefore, it is not considered a prophylactic intervention for immobility-related complications.
Choice C reason: Inserting a urinary catheter is not a prophylactic intervention for preventing complications of immobility. Catheters are used to manage urinary retention or incontinence but can increase the risk of urinary tract infections (UTIs) if not managed properly. They do not address the primary complications associated with immobility, such as DVT or pressure ulcers.
Choice D reason: Using friction-reducing devices is important for preventing pressure ulcers and skin injuries in immobile patients. These devices help minimize friction and shear forces on the skin, which can lead to pressure ulcers. While this is a valuable intervention, it is not as comprehensive as compression stockings in preventing a range of immobility-related complications.
Correct Answer is C
Explanation
Choice A Reason:
The client has full range of motion in her wrist does not necessarily indicate a need to loosen the restraints. Full range of motion suggests that the restraints are not too tight and are allowing for some movement. However, it is important to regularly assess the client’s circulation, skin integrity, and comfort to ensure the restraints are not causing harm.
Choice B Reason:
The client is attempting to remove the restraint is a common behavior in clients who are restrained, especially if they are confused or agitated. While this behavior warrants close monitoring and possibly re-evaluating the need for restraints, it does not necessarily indicate that the restraints need to be loosened. The nurse should assess the client’s overall condition and consider alternative methods to ensure safety.
Choice C Reason:
The client has cyanotic digits is a critical finding that indicates impaired circulation. Cyanosis, or a bluish discoloration of the skin, occurs when there is a lack of oxygen in the blood. This can be a sign that the restraints are too tight and are restricting blood flow to the extremities. In this case, the nurse should immediately loosen the restraints to restore proper circulation and prevent further complications.
Choice D Reason:
The client denies discomfort is a positive finding, indicating that the client is not experiencing pain or distress from the restraints. However, the absence of discomfort does not rule out other potential issues such as impaired circulation or skin breakdown. Regular assessments are necessary to ensure the restraints are being used safely and effectively.
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