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 D

Explanation

Diclofenac, like other NSAIDs, can cause gastrointestinal irritation and bleeding. The client’s symptoms of pallor and fatigue may indicate anemia due to blood loss. Reviewing the client’s hemoglobin level would help the nurse determine if the client is experiencing anemia and if further evaluation and intervention are needed.

A. Advice the client that the medication should start to work in about 30 minutes. B. Administer a stool softener/laxative at the same time as the analgesic. C. Instruct the client to request assistance when ambulating to the bathroom. D. Tell the client to notify the nurse if the pain is not relieved.

Correct Answer is C

Explanation

The correct answer is C. Instruct the client to request assistance when ambulating to the bathroom.

Choice A reason:

Advise the client that the medication should start to work in about 30 minutes.

While it is important to inform the client about the onset of action of the medication, this is not the highest priority. Codeine, an opioid, can cause dizziness and sedation, which increases the risk of falls. Therefore, safety measures take precedence over informing the client about the medication’s onset time.

Choice B reason:

Administer a stool softener/laxative at the same time as the analgesic.

Opioids like codeine can cause constipation, so administering a stool softener or laxative is a good practice. However, this action is not the highest priority when considering the immediate safety of the client. Ensuring the client’s safety from potential falls due to dizziness or sedation is more urgent.

Choice C reason:

Instruct the client to request assistance when ambulating to the bathroom.

This is the correct answer because codeine can cause dizziness, sedation, and orthostatic hypotension, increasing the risk of falls. Ensuring the client requests assistance when moving can prevent potential injuries, making it the highest priority nursing action.

Choice D reason:

Tell the client to notify the nurse if the pain is not relieved.

While it is important for the client to communicate about the effectiveness of pain relief, this is not the highest priority. The immediate concern is the client’s safety due to the sedative effects of codeine. Therefore, preventing falls and injuries takes precedence.

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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

Naxlex Comprehensive Predictor Exams

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