Nokea
A client is receiving a bowel evacuant in preparation for a colonoscopy. The client tells the nurse that he has been 'going to the bathroom about every 30 to 45 minutes' since he started taking the drug and his stools are 'like water.' He reports that he is thirsty and his mouth feels dry. Which nursing diagnosis would the nurse most likely identify?
- A. Risk for Infection
- B. Risk for Injury
- C. Risk for Imbalanced Fluid Volume
- D. Deficient Knowledge
Correct Answer: C
Rationale: The client's report of frequent stools, which is a result of the drug therapy, along with complaints of feeling thirsty and dry mouth suggest the nursing diagnosis of Risk for Imbalanced Fluid Volume due to the large losses of fluid from the body from the drug. There is no evidence to support a risk for infection or deficient knowledge. Risk for Injury would be appropriate if the client was experiencing drowsiness or dizziness in conjunction with the fluid losses.
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A client is prescribed an antidiarrheal drug. The nurse reviews the client's medical record for possible contraindications for use. Which of the following would alert the nurse to a possible contraindication?
- A. Pseudomembranous colitis
- B. Type 1 diabetes
- C. Abdominal pain of unknown origin
- D. Liver disease
- E. Obstructive jaundice
Correct Answer: A,C,E
Rationale: Clients with pseudomembranous colitis, abdominal pain of unknown origin, and obstructive jaundice should not take antidiarrheals.
A client is using chamomile tea as a remedy to treat gastrointestinal upset. When discussing the use of this herb, the nurse would alert the client that contact dermatitis is a possibility if the client has a hypersensitivity to which of the following plants?
- A. Ragweed
- B. Fox glove
- C. Asters
- D. Lavender
- E. Chrysanthemums
Correct Answer: A,C,E
Rationale: Although chamomile is generally safe and nontoxic, the tea is prepared from the pollen-filled flower heads and has resulted in symptoms ranging from contact dermatitis to severe anaphylactic reactions in individuals hypersensitive to ragweed, asters, and chrysanthemums.
After teaching a group of nursing students about laxatives, the instructor determines that the teaching was successful when the students identify which drug as producing the laxative effect by promoting water retention in the fecal mass and softening the stool?
- A. Docusate sodium (Colace)
- B. Methylcellulose (Citrucel)
- C. Bisacodyl (Dulcolax)
- D. Lactulose (Chronulac)
Correct Answer: A
Rationale: Stool softeners, like docusate sodium (Colace) and docusate calcium (Surfak), produce their laxative effect by promoting water retention in the fecal mass and softening the stool. Methylcellulose is a bulk-producing laxative. Bisacodyl is a stimulant laxative. Lactulose is a hyperosmolar laxative.
A physician has prescribed bisacodyl to a client with constipation. The client complains of epigastric pain and a burning sensation after taking the drug. Which of the following instructions should the nurse provide to the client?
- A. Immediately stop taking the drug.
- B. Take antacids between meals.
- C. Take the drug in powdered form.
- D. Avoid milk before taking the drug.
Correct Answer: D
Rationale: The nurse should instruct the client to avoid milk, antacids, H2 antagonists, and proton pump inhibitors 1 to 2 hours before taking the bisacodyl tablets because the enteric coating may dissolve early before reaching the intestinal tract, resulting in gastric lining irritation or dyspepsia and decreasing the laxative effect of the drug. The nurse need not instruct the client to immediately stop taking the drug, take the drug in powdered form, or take antacids between meals as these interventions will not help in preventing gastric lining irritation.
A nurse would most likely expect a primary health care provider to prescribe psyllium (Metamucil) to a client who is experiencing constipation related to which drug?
- A. Spironolactone (Aldactone)
- B. Clonidine (Catapres)
- C. Enalapril (Vasotec)
- D. Fexofenadine (Allegra)
- E. Amitriptyline (Elavil)
Correct Answer: A,B,D,E
Rationale: The following drugs may cause constipation in clients and require the use of a laxative to relieve constipation: anticholinergics, antihistamines (fexofenadine), phenothiazines, tricyclic antidepressants (amitriptyline), opioids, non-potassium-sparing diuretics (spironolactone), iron preparations, barium, clonidine, and calcium- or aluminum-containing antacids.