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?

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.

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

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

Answer and Explanation

The Correct Answer is D

A) Allow the client to take the medication up to 1 hour after breakfast:
Administering sucralfate up to 1 hour after breakfast may not provide optimal effectiveness as it should ideally be taken on an empty stomach to form a protective barrier over irritated areas in the stomach and intestines before food intake. Taking it after breakfast might not allow sufficient time for the medication to coat these areas adequately.

B) Instruct the client to take it when the meal tray is delivered:
Taking sucralfate with meals or when the meal tray is delivered is not recommended as food can interfere with its effectiveness. It is best taken on an empty stomach to allow it to coat the stomach lining without interference from food, ensuring maximum therapeutic benefit.

C) Document the client's refusal of the medication at this time:
Documenting a refusal should only be done if the client declines after receiving appropriate education and understanding. Simply refusing the client's request without providing education on the proper timing for taking sucralfate would not be appropriate.

D) Explain the need to take the medication at least 1 hour before meals:
This is the correct response. Educating the client about the importance of taking sucralfate at least 1 hour before meals ensures optimal effectiveness. This timing allows the medication to form a protective barrier over irritated areas in the stomach and intestines before food intake, maximizing its therapeutic benefit.

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Correct Answer is A

Explanation

A) Worsening headache:
This option is correct. Vasopressin, also known as antidiuretic hormone (ADH), acts to increase water reabsorption in the kidneys, thereby reducing urine output. However, excessive administration of vasopressin can lead to vasoconstriction, which may result in increased intracranial pressure and subsequent headaches. Therefore, worsening headache can be indicative of vasopressin overdose or adverse effects, and it should be promptly reported to the healthcare provider for evaluation and appropriate management.

B) Polyuria:
Polyuria, or excessive urine output, is the opposite effect of vasopressin. While diabetes insipidus is characterized by polyuria due to insufficient ADH secretion or renal responsiveness to ADH, administering vasopressin should decrease urine output. Therefore, polyuria would not be expected as a side effect of vasopressin administration.

C) Polydipsia:
Polydipsia, or excessive thirst, is also a symptom of diabetes insipidus but is not typically associated with vasopressin administration. Vasopressin functions to decrease urine output and, consequently, reduce thirst. Therefore, polydipsia would not be expected as a side effect of vasopressin administration.

D) Low urine specific gravity:
Vasopressin administration is expected to increase urine specific gravity by promoting water reabsorption in the kidneys, leading to more concentrated urine. Therefore, low urine specific gravity would not be an expected side effect of vasopressin administration.

A. Monitor blood pressure. B. Assess urine output. C. Obtain daily weights. D. Perform a bladder scan.

Correct Answer is A

Explanation

A) Monitor blood pressure:
This is the correct answer. Tamsulosin, like other alpha-blockers, can cause orthostatic hypotension, which is characterized by a sudden drop in blood pressure when transitioning from lying down or sitting to standing. Monitoring blood pressure, particularly when initiating therapy or adjusting the dosage, helps detect and manage hypotensive episodes. Clients should be advised to change positions slowly to minimize the risk of falls or injury.

B) Assess urine output:
While tamsulosin can affect urinary function by relaxing smooth muscle in the prostate and bladder neck, it typically does not significantly impact urine output. Therefore, monitoring urine output is not a primary intervention for assessing adverse reactions to tamsulosin.

C) Obtain daily weights:
Tamsulosin is not typically associated with significant fluid retention or changes in body weight. Daily weight measurements are more relevant for assessing fluid balance in clients receiving medications such as diuretics or those with conditions like heart failure or renal disease.

D) Perform a bladder scan:
Tamsulosin does not directly affect bladder volume or urinary retention to the extent that necessitates routine bladder scanning. Bladder scans are typically performed in clients with suspected urinary retention or those at risk for urinary retention due to conditions like BPH, but it's not a standard intervention for monitoring adverse reactions to tamsulosin.

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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

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