A client with psychosis who is receiving an antipsychotic medication is continually rubbing the back of the neck. Which nursing intervention is best for the nurse to implement?

Choice A reason: This is not a correct action for the nurse to include in this client's plan of care. Administering sucralfate once a day, preferably at bedtime, is not the recommended dosage or timing for this medication. Sucralfate is a mucosal protectant that forms a protective barrier over the ulcer and prevents further damage from acid and pepsin. It should be taken four times a day, one hour before meals and at bedtime, to ensure optimal coverage and healing of the ulcer.

Choice B reason: This is the correct action for the nurse to include in this client's plan of care. Giving sucralfate on an empty stomach is essential for the effectiveness of this medication. Sucralfate needs an acidic environment to activate and form a complex with the ulcer site. If the client takes sucralfate with food or beverages, the pH of the stomach may increase and reduce the ability of sucralfate to bind to the ulcer. The client should take sucralfate one hour before meals and at bedtime, and avoid antacids within 30 minutes of taking sucralfate.

Choice C reason: This is not a correct action for the nurse to include in this client's plan of care. Monitoring for electrolyte imbalance is not a specific or relevant intervention for this medication. Sucralfate does not affect the electrolyte levels in the blood, as it is not absorbed systemically and does not alter the renal function. The nurse should monitor the electrolyte levels for other reasons, such as dehydration, vomiting, or diuretic use, but not because of sucralfate therapy.

Choice D reason: This is not a correct action for the nurse to include in this client's plan of care. Assessing for secondary Candida infection is not a common or necessary intervention for this medication. Sucralfate does not increase the risk of fungal infections, as it does not suppress the immune system or alter the normal flora of the GI tract. The nurse should assess for signs of infection, such as fever, leukocytosis, or purulent drainage, for other reasons, such as perforation, abscess, or sepsis, but not because of sucralfate therapy.

Choice A reason: Assessing for orthostatic hypotension is not a priority action before administering labetalol. Orthostatic hypotension is a possible side effect of the drug, but it is not an immediate concern.

Choice B reason: Administering the dose and monitoring the client's BP regularly is not the best action. The client's heart rate is below the normal range of 60 to 100 beats/minute, which indicates bradycardia. Labetalol can further lower the heart rate and cause cardiac complications.

Choice C reason: Applying a telemetry monitor before administering the dose is not necessary. Telemetry monitoring is used to detect cardiac arrhythmias, which are not a common adverse effect of labetalol. The client's heart rate and rhythm should be assessed by auscultation.

Choice D reason: Withholding the scheduled dose and notifying the health care provider is the correct action. The client's heart rate is too low to safely receive labetalol, which is a beta-blocker that can decrease the heart rate and contractility. The health care provider should be informed of the client's vital signs and the need to adjust the medication dosage or frequency.