The nurse assesses a client with intermittent claudication who is receiving pentoxifylline. Which assessment should the nurse perform to determine the eﬀectiveness of the medication?

Evaluate the level of consciousness.

Auscultate bowel sounds.

Measure hourly urinary output.

Monitor numeric pain scale.

Answer and Explanation

The Correct Answer is D

Intermittent claudication is a condition in which there is pain in the legs due to reduced blood ﬂow. Pentoxifylline is a medication that can improve blood ﬂow by reducing the viscosity of the blood. Therefore, to determine the eﬀectiveness of the medication in managing intermittent claudication, the nurse should monitor the client's pain level using a numeric pain scale. This will help to assess if the medication provides pain relief and improving the client's ability to walk without discomfort.

Options a, b, and c are not relevant to the assessment of the eﬀectiveness of pentoxifylline in managing intermittent claudication.

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Correct Answer is C

Explanation

The correct answer is C. Liver function lab results.

Choice A: Weight change in the last month

Weight change is a relevant factor to monitor in patients starting on antidepressants, including duloxetine, as some antidepressants can cause weight gain or loss. However, it is not the most critical information to obtain initially. Monitoring weight can help manage potential side effects and ensure the patient’s overall health, but it does not directly impact the immediate safety and efficacy of starting duloxetine.

Choice B: Recent use of other antidepressants

Recent use of other antidepressants is crucial information because combining duloxetine with other antidepressants, especially MAOIs (Monoamine Oxidase Inhibitors), can lead to serious interactions such as serotonin syndrome. This condition can be life-threatening and requires careful management. However, while this information is important, it is not as immediately critical as liver function tests when starting duloxetine.

Choice C: Liver function lab results

Liver function lab results are the most important information for the nurse to obtain. Duloxetine is metabolized in the liver, and patients with pre-existing liver conditions or impaired liver function are at higher risk for hepatotoxicity. Monitoring liver function is essential to prevent severe liver damage, which can be life-threatening. Baseline liver function tests help ensure that the patient can safely metabolize the medication and identify any potential issues early.

Choice D: Family history of mental illness

Family history of mental illness can provide valuable context for understanding the patient’s condition and potential genetic predispositions. It can also help in tailoring the treatment plan and anticipating the patient’s response to medication. However, while this information is useful for long-term management, it is not as immediately critical as liver function tests when initiating duloxetine therapy.

A. Determine if the full course of the initial prescription of medication was taken. B. Explain that the diarrhea may be an adverse eﬀect that requires further evaluation. C. Oﬀer instructions about the use of an over-the-counter antidiarrheal medication. D. advise that the infection has returned, and additional medication will be needed.

Correct Answer is B

Explanation

Nitrofurantoin is an antibiotic commonly used to treat urinary tract infections. One of the adverse eﬀects of nitrofurantoin is diarrhea, which may be severe and watery. Therefore, it is important for the home care nurse to inform the client that the diarrhea may be a side eﬀect of the medication and requires further evaluation. The nurse should instruct the client to stop taking the medication and contact their healthcare provider for further assessment and treatment. The nurse should also assess the client's ﬂuid and electrolyte status and monitor for signs of dehydration.

Option a is important to consider, but it does not address the potential adverse eﬀect of the medication.

Option c may be appropriate in some cases, but it is not the priority intervention at this time.

Option d is not necessarily true and may cause unnecessary alarm to the client.

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The nurse assesses a client with intermittent claudication who is receiving pentoxifylline. Which assessment should the nurse perform to determine the eﬀectiveness of the medication?

Nursing Test Bank

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