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 A
Explanation
Choice A reason: Hematemesis is the vomiting of blood, which can indicate a serious gastrointestinal bleeding caused by ibuprofen. This is a life-threatening condition that requires immediate medical attention. Therefore, the nurse should report this finding to the healthcare provider as soon as possible.
Choice B reason: Insomnia is the difficulty in falling asleep or staying asleep. It can be a side effect of ibuprofen, but it is not as serious or urgent as hematemesis. The nurse can advise the client to take ibuprofen with food or milk, avoid caffeine and alcohol, and practice good sleep hygiene.
Choice C reason: Dizziness is the feeling of lightheadedness, faintness, or unsteadiness. It can also be a side effect of ibuprofen, but it is usually mild and transient. The nurse can instruct the client to rise slowly from a sitting or lying position, drink plenty of fluids, and avoid driving or operating machinery if dizzy.
Choice D reason: Nausea is the feeling of discomfort or unease in the stomach that may lead to vomiting. It can also be a side effect of ibuprofen, but it is usually manageable with simple measures. The nurse can suggest the client to take ibuprofen with food or milk, eat small and frequent meals, and avoid spicy or fatty foods.
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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