A nurse is caring for a client who has a prescription for clopidogrel.
Which of the following actions should the nurse plan to take?
Administer the medication with each meal.
Have suction equipment at the bedside.
Monitor the client for black, tarry stools.
Initiate contact precautions.
The Correct Answer is C
The correct answer is choice C. Monitor the client for black, tarry stools.
Choice A rationale:
Administering clopidogrel with each meal is not necessary. Clopidogrel can be taken with or without food. The primary concern with clopidogrel is its potential to cause bleeding, so monitoring for signs of bleeding is more critical.
Choice B rationale:
Having suction equipment at the bedside is not specifically required for clients taking clopidogrel. This action is more relevant for clients at risk of airway obstruction or those undergoing procedures that might require suctioning.
Choice C rationale:
Monitoring the client for black, tarry stools is essential because it can indicate gastrointestinal bleeding, a known side effect of clopidogrel. This medication increases the risk of bleeding, so observing for signs of internal bleeding, such as melena (black, tarry stools), is crucial.
Choice D rationale:
Initiating contact precautions is not necessary for clients taking clopidogrel. Contact precautions are typically used to prevent the spread of infections, not for managing clients on antiplatelet therapy.
By understanding these rationales, the nurse can ensure the safe administration and monitoring of clopidogrel therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Checking the client's blood pressure is not the priority action when administering digoxin. Although monitoring blood pressure is essential in the overall care of a client with heart failure, the most critical parameter to assess before administering digoxin is the client's apical pulse.
Choice B rationale:
Measuring the client's apical pulse is the correct action to take before administering digoxin. Digoxin is a medication commonly prescribed for heart failure, and it has a narrow therapeutic range. It primarily works by increasing the force of the heart's contractions, and an excessively low heart rate (bradycardia) is a potential side effect of digoxin. Therefore, it is crucial to assess the client's apical pulse to ensure it is within the recommended range (usually above 60 beats per minute) before administering the medication. If the pulse rate is below the recommended range, the nurse should withhold the digoxin and notify the healthcare provider.
Choice C rationale:
Offering the client a light snack is not a necessary action before administering digoxin. While it is important to consider the client's dietary needs, it is not directly related to the administration of digoxin. However, if the client has nausea or vomiting, which can be a side effect of digoxin, a light snack might be offered after the medication.
Choice D rationale:
Weighing the client is not the immediate action to take before administering digoxin. Although daily weights can be important for assessing fluid balance in clients with heart failure, it is not the priority before administering digoxin. Monitoring the client's apical pulse is the most critical step in this context.
Correct Answer is C
Explanation
Choice A rationale:
"Pitting edema of the lower legs.”. Pitting edema is a common sign of congestive heart failure (CHF), and it often occurs bilaterally in the lower extremities. While this is a potential finding in left-sided heart failure, it is not specific to it.
Choice B rationale:
"Jugular venous distention.”. Jugular venous distention (JVD) is more indicative of right-sided heart failure or elevated central venous pressure. It is not a typical finding in left-sided heart failure.
Choice C rationale:
"Shortness of breath while lying down.”. This is a classic symptom of left-sided heart failure, known as orthopnea. When the patient lies flat, fluid that has accumulated in the lungs can lead to difficulty breathing. Patients with left-sided heart failure often find relief by sleeping with their upper body elevated.
Choice D rationale:
"Right upper quadrant pain.”. Right upper quadrant pain is not a typical finding in left-sided heart failure. It may be associated with issues related to the liver or gallbladder but is not directly related to heart failure.
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