A client who is receiving sodium polystyrene sulfonate reports having two watery stools since starting the medication the previous day. Which action should the practical nurse (PN) take?
Recommend that the client increase fiber in the diet.
Report the liquid stool to the healthcare provider.
Explain that this is a desired effect of the medication.
Withhold the medication until the diarrhea stops.
The Correct Answer is C
A. Recommend client increase fiber intake: Not necessary; diarrhea is due to medication effect.
B. Report the liquid stool to the healthcare provider: Not necessary unless excessive diarrhea or dehydration occurs.
C. Explain that this is a desired effect of the medication: Kayexalate removes potassium through the stool; watery stools show it is working.
D. Withhold the medication until diarrhea stops: Only done if severe diarrhea or electrolyte imbalance occurs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Redness of the cheek under the cannula: Indicates skin irritation, but can usually be managed locally; not the most urgent.
B. Dry, cracked mucous membranes: Suggests dryness from oxygen but not immediately life-threatening.
C. Encrustations on both of the eyelids: Could indicate infection or poor hygiene but less urgent than neurological changes.
D. Drooping of the right side of the mouth: This could indicate a new-onset stroke (facial droop), which is a neurological emergency requiring immediate reporting.
Correct Answer is B
Explanation
A. Encourage the client to resume normal activities after medication administration:
Activity should be limited until pain is controlled and healing is adequate.
B. Implement ongoing assessments for signs of shallow or slow breathing:
Hydrocodone/acetaminophen is an opioid combination; opioids can cause respiratory depression, requiring monitoring.
C. Assess the skin daily for areas of ecchymosis or other signs of bleeding:
This is not the primary concern for an opioid; bleeding risk is not significant unless the client is on anticoagulants.
D. Observe the client for involuntary movements of the lips and tongue:
This relates to tardive dyskinesia, associated with antipsychotics, not opioids.
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