A med-surg patient is scheduled to receive docusate (Colace) at 9am. The night nurse advises the patient had two loose stools during her shift. The nurse would anticipate:
Administering half of the scheduled dose of Colace
Administering the scheduled dose of Colace
Inserting a rectal tube to prevent excoriation
Holding the scheduled dose of Colace and notifying the ordering physician
The Correct Answer is D
Choice A reason: Administering half of the scheduled dose of Colace is not the correct action for the nurse who is caring for a patient who had two loose stools during the night shift. Colace is the brand name of docusate, which is a stool softener that works by increasing the amount of water and fat in the stool, making it easier to pass. Colace is used to treat and prevent constipation, which is a condition of infrequent or hard bowel movements. Colace is not indicated for diarrhea, which is a condition of frequent and loose bowel movements. Administering half of the scheduled dose of Colace may not be enough to prevent constipation, and it may also worsen diarrhea by adding more water and fat to the stool.
Choice B reason: Administering the scheduled dose of Colace is not the correct action for the nurse who is caring for a patient who had two loose stools during the night shift. Colace is the brand name of docusate, which is a stool softener that works by increasing the amount of water and fat in the stool, making it easier to pass. Colace is used to treat and prevent constipation, which is a condition of infrequent or hard bowel movements. Colace is not indicated for diarrhea, which is a condition of frequent and loose bowel movements. Administering the scheduled dose of Colace may not be necessary to prevent constipation, and it may also worsen diarrhea by adding more water and fat to the stool.
Choice C reason: Inserting a rectal tube to prevent excoriation is not the correct action for the nurse who is caring for a patient who had two loose stools during the night shift. A rectal tube is a device that is inserted into the rectum and connected to a drainage bag, which collects the stool and prevents leakage and skin irritation. A rectal tube is used for patients who have fecal incontinence, which is the inability to control bowel movements. A rectal tube is not indicated for patients who have diarrhea, which is a condition of frequent and loose bowel movements. Inserting a rectal tube may not be effective to prevent excoriation, and it may also cause complications such as infection, bleeding, or perforation.
Choice D reason: Holding the scheduled dose of Colace and notifying the ordering physician is the correct action for the nurse who is caring for a patient who had two loose stools during the night shift. Colace is the brand name of docusate, which is a stool softener that works by increasing the amount of water and fat in the stool, making it easier to pass. Colace is used to treat and prevent constipation, which is a condition of infrequent or hard bowel movements. Colace is not indicated for diarrhea, which is a condition of frequent and loose bowel movements. Holding the scheduled dose of Colace may be appropriate to avoid further diarrhea, and notifying the ordering physician may be necessary to determine the cause and the treatment of diarrhea
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: "I am not ready to eat lunch yet." is not a concerning statement for the patient who has completed their Albuterol nebulizer treatment. Albuterol is a medication that relaxes the muscles in the airways and increases the airflow to the lungs, which can improve the breathing and reduce the wheezing in patients with asthma¹. Albuterol does not affect the appetite or the digestion directly, but it may cause some side effects such as nausea, vomiting, or dry mouth, which may reduce the desire to eat. The nurse should respect the patient's preference and offer them food later when they are ready.
Choice B reason: "It feels like my heart is racing." is a concerning statement for the patient who has completed their Albuterol nebulizer treatment. Albuterol is a medication that relaxes the muscles in the airways and increases the airflow to the lungs, but it also stimulates the beta receptors in the heart, which can increase the heart rate and the blood pressure¹. This can cause side effects such as palpitations, chest pain, or arrhythmias, especially in patients with underlying heart conditions or those who take other medications that affect the heart. The nurse should monitor the patient's vital signs, report the finding to the prescriber, and prepare to administer interventions such as betablockers or calcium channel blockers to lower the heart rate and prevent complications.
Choice C reason: "It is easier to breathe now." is not a concerning statement for the patient who has completed their Albuterol nebulizer treatment. Albuterol is a medication that relaxes the muscles in the airways and increases the airflow to the lungs, which can improve the breathing and reduce the wheezing in patients with asthma¹. This is the expected and desired outcome of the Albuterol nebulizer treatment, which indicates that the medication is effective and the patient is responding well. The nurse should document the patient's response and continue to assess the patient's respiratory status and oxygen saturation.
Choice D reason: "I can breathe better now." is not a concerning statement for the patient who has completed their Albuterol nebulizer treatment. Albuterol is a medication that relaxes the muscles in the airways and increases the airflow to the lungs, which can improve the breathing and reduce the wheezing in patients with asthma¹. This is the expected and desired outcome of the Albuterol nebulizer treatment, which indicates that the medication is effective and the patient is responding well. The nurse should document the patient's response and continue to assess the patient's respiratory status and oxygen saturation.
Correct Answer is C
Explanation
Choice A reason: This is incorrect. SQ (subcutaneous) administration involves injecting a drug into the fatty tissue under the skin. This route is slower than IV or IM administration, as the drug has to diffuse through the tissue before reaching the bloodstream.
Choice B reason: This is incorrect. PO (by mouth) administration involves swallowing a drug and absorbing it through the digestive system. This route is the slowest of all, as the drug has to pass through the stomach and the liver before reaching the bloodstream. The drug may also be affected by the first pass effect, which reduces its bioavailability.
Choice C reason: This is correct. IV (intravenous) administration involves injecting a drug directly into a vein. This route is the fastest of all, as the drug enters the bloodstream immediately and reaches the target site quickly. The drug also has 100% bioavailability, meaning none of it is lost or degraded.
Choice D reason: This is incorrect. IM (intramuscular) administration involves injecting a drug into a muscle. This route is faster than SQ or PO administration, as the drug can be absorbed by the capillaries in the muscle. However, it is still slower than IV administration, as the drug has to cross the muscle membrane before reaching the bloodstream.
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