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) Positive guaiac of stool:
A positive guaiac test indicates the presence of occult (hidden) blood in the stool, which may suggest gastrointestinal bleeding. Given the client’s history of heartburn, indigestion, and self-treatment with ibuprofen and antacids, gastrointestinal irritation or ulceration may be occurring, leading to bleeding. Gastrointestinal bleeding can cause fatigue, dizziness, and other symptoms. Therefore, it is essential to report this finding immediately to the healthcare provider for further evaluation and management.

B) Hematocrit 42% (0.42 volume fraction):
A hematocrit level within the reference range (42% to 52%) is considered normal. While a slight decrease in hematocrit may indicate anemia, it is not an urgent finding that requires immediate reporting. The client’s hematocrit level of 42% is within the normal range, so it does not warrant immediate concern.

C) Gastric pH 2.0:
A gastric pH of 2.0 falls within the normal range (1.5 to 3.5) for gastric acid pH. This finding indicates normal gastric acidity and does not suggest an acute problem that requires immediate reporting to the healthcare provider.

D) Hemoglobin 13 g/dL (130 g/L):
A hemoglobin level of 13 g/dL is slightly below the lower end of the reference range (14 to 18 g/dL) but does not indicate a critical condition requiring immediate intervention. While it may suggest mild anemia, it is not an urgent finding that necessitates immediate reporting to the healthcare provider.

A. The viral load can be decreased to an undetectable level. B. HIV infection is not cured by the antiretroviral regimen. C. The medications can decrease acquired AIDS related complications. D. Antiretroviral medication prevents the transmission of the virus.

Correct Answer is D

Explanation

Answer: D. Antiretroviral medication prevents the transmission of the virus.

Rationale:

A. The viral load can be decreased to an undetectable level:
This statement reflects an accurate understanding of antiretroviral therapy. Effective treatment can reduce the viral load to undetectable levels, which is a key goal of HIV treatment, allowing individuals to live healthier lives and reducing the risk of transmitting the virus to others.

B. HIV infection is not cured by the antiretroviral regimen:
This statement is also accurate. Antiretroviral therapy (ART) effectively manages HIV infection but does not cure it. Patients need to remain on medication for life to control the virus and maintain their health.

C. The medications can decrease acquired AIDS-related complications:
This statement is correct as well. Antiretroviral medications can help manage HIV and prevent the progression to AIDS, thereby reducing the likelihood of complications associated with AIDS, such as opportunistic infections.

D. Antiretroviral medication prevents the transmission of the virus:
This statement requires additional instruction because, while effective antiretroviral therapy can significantly reduce the risk of transmission, it does not entirely prevent it. Patients with an undetectable viral load have a greatly reduced risk of transmitting HIV to sexual partners (often summarized as "U=U" or "Undetectable = Untransmittable"), but it is crucial to understand that there is still a small risk involved. Therefore, additional education is necessary to clarify the need for continued safe practices, such as using condoms, even when on effective therapy.

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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

Correct Answer is A

Explanation

The nurse is teaching a client who has been diagnosed with HIV about the antiretroviral medication regimen. Which statement provided by the client requires additional instruction by the nurse?

Correct Answer is D

Explanation

Rationale:

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