After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?
Auscultate for bowel sounds in all quadrants.
Measure the client's fluid intake and output.
Ask the client about gastrointestinal pain.
Monitor the client's serum electrolyte levels.
The Correct Answer is C
A. Auscultate for bowel sounds in all quadrants: While assessing bowel sounds can help evaluate gastrointestinal function, it does not assess the effectiveness of a proton pump inhibitor. PPIs primarily work to reduce gastric acid secretion, not to change bowel sounds.
B. Measure the client's fluid intake and output: Measuring fluid intake and output is important for general fluid balance but does not specifically assess the effectiveness of a PPI. This action is more relevant to other concerns such as hydration status.
C. Ask the client about gastrointestinal pain: The primary indication for PPIs is the treatment of gastrointestinal conditions like acid reflux, ulcers, or GERD. Asking the client about gastrointestinal pain directly assesses the effectiveness of the PPI in reducing symptoms such as heartburn or discomfort.
D. Monitor the client's serum electrolyte levels: While electrolyte imbalances can be a concern with prolonged PPI use, monitoring electrolytes is not the immediate method to assess PPI effectiveness. Reduction in gastrointestinal symptoms is a more direct indicator.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Rationale for correct findings:
- Fasting 1-hour glucose screen: 164 mg/dL (9.1 mmol/L): The fasting glucose of 164 mg/dL is elevated, indicating impaired glucose metabolism, which suggests the possibility of gestational diabetes.
- 3-hour glucose tolerance test: Fasting blood sugar 168 mg/dL (9.3 mmol/L): The fasting blood sugar of 168 mg/dL is above the normal threshold of 140 mg/dL, reinforcing the suspicion of gestational diabetes.
- 2-hour postprandial glucose: 220 mg/dL (12.2 mmol/L): A postprandial glucose level of 220 mg/dL is significantly above the normal limit of 140 mg/dL, further indicating gestational diabetes.
- Fourth child with macrosomia: 9 pounds (4.08 kg) at 41 weeks gestation: Macrosomia is often associated with gestational diabetes. The fourth child weighing 9 pounds suggests the possibility of undiagnosed gestational diabetes during the previous pregnancy, which could be recurring in the current pregnancy.
Rationale for incorrect Findings:
- Client is at 28 weeks and has been receiving prenatal care since 8 weeks gestation: The client’s consistent prenatal care since 8 weeks indicates early and regular monitoring, reducing the likelihood of other major complications.
Correct Answer is A
Explanation
A. Facilitate a consultation for speech therapy: Aphasia and difficulty swallowing are common after a CVA. A speech therapist can assess and provide interventions to address both speech and swallowing issues, improving communication and reducing the risk of aspiration or choking.
B. Arrange for daily home care assistance: While home care assistance may be necessary later, the immediate priority is addressing the client's communication and swallowing difficulties through therapy and clinical interventions.
C. Use pictures and gestures to communicate: This is helpful for the client’s communication, but it should be seen as an adjunct to speech therapy, not a substitute. Speech therapy provides targeted interventions to improve both speech and swallowing.
D. Initiate passive range of motion exercises: Although range of motion exercises are important for preventing joint contractures and promoting mobility, addressing the client’s swallowing and communication issues is a more immediate priority.
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