The nurse is planning to administer the antiulcer gastrointestinal (GI) agent sucralfate to a client with peptic ulcer disease. Which action should the nurse include in this client's plan of care?
Give sucralfate on an empty stomach.
Assess for secondary Candida infection.
Administer sucralfate once a day, preferably at bedtime.
Monitor for electrolyte imbalance.
The Correct Answer is A
Choice A reason: This is the correct action to include in the client's plan of care, as sucralfate should be given on an empty stomach, at least one hour before meals and at bedtime. Sucralfate is a mucosal protectant that forms a protective barrier over the ulcer and prevents further damage from acid and pepsin. It requires an acidic environment to work, so it should not be taken with food or antacids.
Choice B reason: This is not a relevant action to include in the client's plan of care, as sucralfate does not cause or increase the risk of secondary Candida infection. Candida infection is a fungal infection that can affect the mouth, throat, esophagus, or vagina. It is more common in clients who use antibiotics, corticosteroids, or immunosuppressants, but not sucralfate.
Choice C reason: This is not an accurate action to include in the client's plan of care, as sucralfate should be administered four times a day, not once a day. Sucralfate has a short duration of action, so it needs to be taken frequently to maintain its protective effect on the ulcer.
Choice D reason: This is not a necessary action to include in the client's plan of care, as sucralfate does not cause or affect electrolyte imbalance. Electrolyte imbalance is an abnormality in the levels of sodium, potassium, calcium, magnesium, or other minerals in the blood. It can be caused by dehydration, vomiting, diarrhea, kidney disease, or other conditions, but not sucralfate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.1"]
Explanation
To find out how many mL of dalteparin are needed for 2500 units, we need to use a proportion formula:
- (units of dalteparin)/(mL of dalteparin) = (units of dalteparin prescribed)/(mL of dalteparin needed)
- We can plug in the values that we know into the formula:
- (5000 units)/(0.2 mL) = (2500 units)/(x mL)
- We can cross-multiply and solve for x:
- 5000x = 2500 x 0.2
- x = (2500 x 0.2)/5000
- x = 0.1
- Therefore, the nurse should administer 0.1 mL of dalteparin to deliver 2500 units of the medication.
Correct Answer is D
Explanation
Choice A reason: Telling the client to notify the nurse if the pain is not relieved is an important nursing action, but it is not the highest priority. The nurse should assess the client's pain level before and after administering the medication, and evaluate its effectiveness. If the pain is not relieved, the nurse should report it to the prescriber and consider other interventions.
Choice B reason: Advising the client that the medication should start to work in about 30 minutes is an informative nursing action, but it is not the highest priority. The nurse should educate the client about the expected onset, peak, and duration of action of the medication, and how to take it safely and effectively. However, this does not address any immediate risks or needs of the client.
Choice C reason: Administering a stool softener/laxative at the same time as the analgesic is a preventive nursing action, but it is not the highest priority. The nurse should anticipate and prevent potential side effects of the medication, such as constipation, which can be caused by codeine. However, this does not address any urgent or emergent issues of the client.
Choice D reason: Instructing the client to request assistance when ambulating to the bathroom is the highest priority nursing action, as it addresses a serious safety concern of the client. The nurse should protect the client from falls and injuries, which can be caused by codeine's sedative and drowsy effects. The nurse should also monitor the client's respiratory rate and level of consciousness, as codeine can cause respiratory depression and altered mental status.
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