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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Neutropenic precautions are necessary when the WBC count is critically low, typically below the normal range. Since the client’s WBC count is now within the normal range, these precautions are no longer required.

Choice B reason: Filgrastim is designed to increase white blood cell (WBC) production in individuals with neutropenia. In this case, the client’s WBC count has increased from 2,500/mm³ (2.5 x 10⁹/L) to 5,000/mm³ (5 x 10⁹/L), reaching the lower limit of the normal reference range (5,000 to 10,000/mm³ or 5 to 10 x 10⁹/L). This indicates that the medication has achieved its desired effect, and it is appropriate to inform the client of this positive outcome.

Choice C reason:reason: Reviewing culture and sensitivity reports would be relevant if there was evidence of infection or a need to evaluate ongoing treatment for an infection. This is not indicated by the scenario provided.

Choice D reason: While assessing vital signs is generally important, there is no indication in this scenario that an acute issue requiring immediate vital sign monitoring is present.

A. Peripheral edema. B. Muscle tenderness. C. Nausea and vomiting. D. Excessive bruising.

Correct Answer is B

Explanation

Choice A reason: Peripheral edema is not a common side effect of atorvastatin, and it is not related to increased CK levels. CK is an enzyme that is released when muscle tissue is damaged. Peripheral edema is more likely to be caused by heart failure, kidney disease, or venous insufficiency.

Choice B reason: Muscle tenderness is a sign of myopathy, which is a rare but serious adverse effect of atorvastatin. Myopathy is a condition where muscle fibers are damaged and inflamed, leading to muscle weakness and pain. Increased CK levels indicate muscle injury and can be a marker of myopathy. The nurse should monitor the client for muscle symptoms and report them to the prescriber.

Choice C reason: Nausea and vomiting are common gastrointestinal side effects of atorvastatin, but they are not associated with increased CK levels. Nausea and vomiting can be managed by taking the medication with food or reducing the dose.

Choice D reason: Excessive bruising is not a typical side effect of atorvastatin, and it is not linked to increased CK levels. Excessive bruising can be caused by bleeding disorders, anticoagulant therapy, or trauma. The nurse should assess the client for other signs of bleeding, such as hematuria, hematemesis, or melena.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After receiving five doses of filgrastim, the nurse notes that the client's white blood cell count has increased from 2,500/mm3 (2.5 x 109/L) to 5,000/mm3 (5 x 109/L). Which action should the nurse implement? White Blood Cell (WBC) [Reference Range: 5000 to 10,000/mm3 (5 to 10 x 109/L)]

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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