Nokea
A client with peptic ulcer disease is scheduled to receive doses of pantoprazole IV and sucralfate PO before breakfast at 0730. The client reports experiencing heartburn when the nurse brings the scheduled medications. Which action should the nurse take?
- A. Hold the dose of IV pantoprazole until the client has finished eating breakfast.
- B. Provide a PRN dose of antacid along with the scheduled medications.
- C. Instruct the client to take the dose of sucralfate PO while eating breakfast.
- D. Administer both of the medications before breakfast as scheduled.
Correct Answer: D
Rationale: Pantoprazole and sucralfate should be administered before breakfast to maximize acid suppression and ulcer protection. Delaying pantoprazole reduces efficacy, antacids interfere with sucralfate absorption, and sucralfate requires an empty stomach.
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A client with heart failure (HF) develops hyperaldosteronism and spironolactone is prescribed. Which instruction should the nurse include in the client's plan of care?
- A. Limit the intake of foods high in potassium.
- B. Cover your skin before going outside.
- C. Monitor skin for excessive bruising.
- D. Replace salt with a salt substitute.
Correct Answer: A
Rationale: Spironolactone is potassium-sparing, so limiting potassium-rich foods prevents hyperkalemia. Sun protection, bruising, and salt substitutes (often potassium-based) are not primary concerns.
A female client with osteoporosis has been taking a weekly dose of oral risedronate for several weeks. The client calls the clinic nurse to report increasing 'heartburn.' How should the nurse respond?
- A. Ask the client to describe how she takes the medication.
- B. Remind the client to take the medication with plenty of water.
- C. Advise the client to go to the nearest emergency department.
- D. Suggest use of an antacid two hours after the medication.
Correct Answer: A
Rationale: Risedronate can cause esophageal irritation if not taken properly. Assessing the client’s administration technique (e.g., with water, staying upright) identifies potential causes of heartburn, guiding further intervention.
A client with chronic asthma receives a prescription for montelukast, a leukotriene modifier. Which statement by the client indicates to the nurse that medication teaching was effective?
- A. I should take this medication only when I am having an asthma attack.
- B. I will not need to use my inhalers twice a day when I start this medicine.
- C. This medication will stop an asthma attack immediately.
- D. I will take the tablet every evening to control my asthma.
Correct Answer: D
Rationale: Montelukast is a maintenance medication taken regularly (often in the evening) to control asthma. It is not for acute attacks or to replace inhalers, indicating the client understands its role.
Furosemide is prescribed for a client with a history of heart failure (HF). Which foods should the nurse encourage this client to eat?
- A. Cheese, milk, and yogurt.
- B. Liver, beef, and chicken.
- C. Bananas, oranges, and peaches.
- D. Pasta, cereal, and bread.
Correct Answer: C
Rationale: Furosemide causes potassium loss, so potassium-rich foods like bananas, oranges, and peaches should be encouraged. Dairy, meats, and carbohydrates do not address potassium needs.
History and physical
POD 5
1015
The client is alert and oriented. Rates her pain a 3 on a 0 to 10 pain scale. The client says that she has fullness in her abdomen. Heart sounds are regular and rhythmic. Pulses 1+ in all extremities and equal. Her last bowel movement was POD 2. Healthcare provider notified. The client voided 150 mL of urine.
1100
Bisacodyl suppository given as prescribed.
Reported slight rectal burning when administered.
Nurses notes
POD 5
1015
The client is alert and oriented. Rates her pain a 3 on a 0 to 10 pain scale. The client says that she has fullness in her abdomen. Heart sounds are regular and rhythmic. Pulses 1+ in all extremities and equal. Her last bowel movement was POD 2. Healthcare provider notified. The client voided 150 mL of urine.
1100
Bisacodyl suppository given as prescribed.
Reported slight rectal burning when administered.
1200
Rates her pain a 7 on a 0 to 10 pain scale. Pulses 1+ in all extremities and equal. Morphine given as prescribed. She asked to use the restroom but felt dizzy. Voided 600 mL urine in the bedpan.
Flowsheet
Vital Signs
POD 5
1015
Temperature 97.2° F (36.2° C) orally
Heart rate 77 beats/minute
Respiratory rate 14 breaths/minute
Blood pressure 119/75 mm Hg
1200
• Temperature 97° F (36.1° C) orally
Review H and P, nurse's notes, flow sheet, and prescriptions. Mark whether the assessment finding represents a therapeutic result of the lactulose administered, a non-therapeutic side-effect, or an unrelated finding. Each row must have only one option selected.
- A. Reported slight rectal burning sensation: Non-therapeutic side effect
- B. Large, soft stool: Therapeutic result
- C. Dizziness: Non-therapeutic side effect
- D. Pain level of 3 on a 0 to 10 pain scale: Unrelated finding
- E. 600ml of urine: Unrelated finding
- F. Abdomen soft and flat: Unrelated finding
- G. Respiratory rate 13 breaths/min: Unrelated finding
Correct Answer:
Rationale: The question refers to bisacodyl, not lactulose. A: Rectal burning is a bisacodyl side effect. B: Soft stool is the therapeutic effect. C: Dizziness may relate to morphine, not bisacodyl. D, E, F, G: Pain, urine output, abdomen, and respiratory rate are unrelated to bisacodyl.