The nurse is administering sucralfate to a client with stomatitis secondary to chemotherapy. The client wants to take the medication after breakfast. How should the nurse respond?

Document the client’s refusal of the medication at this time.

Explain the need to take the medication at least 1 hour before meals.

Allow the client to take the medication up to 1 hour after breakfast.

Instruct the client to take it when the meal tray is delivered.

Answer and Explanation

The Correct Answer is B

Choice A reason:

Documenting the client’s refusal of the medication at this time is not the best response. While it is important to document any refusal of medication, the nurse should first educate the client on the proper administration of sucralfate. Sucralfate works by forming a protective barrier over ulcers, and it is most effective when taken on an empty stomach, at least 1 hour before meals.

Choice B reason:

Explaining the need to take the medication at least 1 hour before meals is the correct response. Sucralfate should be taken on an empty stomach to ensure it can effectively coat the stomach lining and protect it from acid. Taking it before meals maximizes its efficacy in treating and preventing ulcers.

Choice C reason:

Allowing the client to take the medication up to 1 hour after breakfast is not appropriate. Sucralfate needs to be taken on an empty stomach to form a protective barrier over the ulcer. Taking it after a meal would reduce its effectiveness, as the presence of food can interfere with its action.

Choice D reason:

Instructing the client to take it when the meal tray is delivered is incorrect. Sucralfate should be taken on an empty stomach, at least 1 hour before meals, to ensure it can properly coat the stomach lining and provide the necessary protection against stomach acid

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Correct Answer is A

Explanation

Choice A reason: Baclofen is a muscle relaxant that can cause side effects such as dizziness and fatigue, especially when starting the medication or adjusting the dose1. These symptoms are usually temporary and may subside as the body adjusts to the medication. Advising the client to avoid hazardous activities, such as driving or operating heavy machinery, helps prevent accidents and ensures safety while the body adapts to the new medication.

Choice B reason: Increasing the intake of fluids and high-protein foods is generally good advice for overall health but is not specifically related to managing the side effects of baclofen. While staying hydrated and maintaining a balanced diet can support overall well-being, it does not directly address the dizziness and fatigue caused by baclofen.

Choice C reason: Stopping the medication immediately is not recommended without consulting a healthcare provider. Abruptly discontinuing baclofen can lead to withdrawal symptoms, including hallucinations and seizures4. It is important to follow a healthcare provider’s guidance when adjusting or stopping any medication.

Choice D reason: Obtaining transportation to the emergency department is not necessary unless the symptoms are severe or accompanied by other concerning signs, such as difficulty breathing or chest pain. Mild to moderate dizziness and fatigue are common side effects of baclofen and can typically be managed with caution and monitoring.

A. Monitor skin for excessive bruising. B. Replace salt with a salt substitute. C. Cover your skin before going outside. D. Limit the intake of foods high in potassium.

Correct Answer is D

Explanation

Choice A Reason:

Spironolactone is a potassium-sparing diuretic often prescribed for heart failure. While monitoring for side effects is important, excessive bruising is not a common side effect of spironolactone. Bruising might be more relevant for patients on anticoagulants or those with clotting disorders.

Choice B Reason:

Replacing salt with a salt substitute is not advisable for patients on spironolactone. Many salt substitutes contain potassium chloride, which can lead to hyperkalemia (high potassium levels) when combined with spironolactone. Hyperkalemia can cause serious cardiac issues, including arrhythmias.

Choice C Reason:

Covering the skin before going outside is not specifically related to the use of spironolactone. This advice might be more relevant for medications that cause photosensitivity, such as certain antibiotics or diuretics like hydrochlorothiazide, but not spironolactone.

Choice D Reason:

Limiting the intake of foods high in potassium is crucial for patients taking spironolactone. Spironolactone can increase potassium levels in the blood, and consuming high-potassium foods (like bananas, oranges, and potatoes) can exacerbate this effect, leading to hyperkalemia. Hyperkalemia can be dangerous and cause symptoms such as muscle weakness, fatigue, and cardiac arrhythmias.

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The nurse is administering sucralfate to a client with stomatitis secondary to chemotherapy. The client wants to take the medication after breakfast. How should the nurse respond?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with multiple sclerosis starts a new prescription, baclofen, to control muscle spasticity. Three days later, the client calls the clinic nurse and reports feeling fatigued and dizzy. Which instruction should the nurse provide?

Correct Answer is A

Explanation

A client with heart failure (HF) develops hyperaldosteronism and spironolactone is prescribed. Which instruction should the nurse include in the client’s plan of care?

Correct Answer is D

Explanation

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