A patient is scheduled to receive intravenous acyclovir.

What should the nurse do first before administering the scheduled dose?

Choice A rationale
A persistent cough is not directly related to the administration of famotidine. Famotidine is a histamine-2 blocker that works by decreasing the amount of acid the stomach produces. It is used to treat and prevent ulcers in the stomach and intestines and to treat conditions in which the stomach produces too much acid. A persistent cough could be a symptom of many other conditions, but it is not a direct indicator of the effectiveness or ineffectiveness of famotidine.
Choice B rationale
The absence of a sour taste in the mouth, often associated with acid reflux, could suggest that famotidine is working as it should. However, the absence of a sour taste does not definitively indicate that the medication has had its intended effect, as the patient may not have experienced this symptom even before taking the medication.
Choice C rationale
Famotidine is used to decrease the amount of acid in the stomach. A normal stomach pH is typically around 1.5 to 3.5, which is highly acidic. If a patient’s stomach pH is measured at 5, which is less acidic than normal, it could suggest that the famotidine has not had its intended effect of reducing stomach acid.
Choice D rationale
While headaches are listed as a common side effect of famotidine, the presence of headaches does not necessarily suggest that the medication has not had its intended effect. Headaches could be caused by a variety of factors and are not a direct indicator of the level of stomach acid or the effectiveness of famotidine.

Choice A rationale
A client with a hip fracture and is on bedrest for 4 weeks may indeed experience constipation due to decreased physical activity. However, this situation would not necessarily require the nurse to question the order for psyllium. Psyllium is a bulk-forming laxative that can help relieve constipation by increasing stool bulk and improving bowel regularity.
Choice B rationale
Morphine is an opioid medication that can cause constipation as a side effect. Therefore, a client who is experiencing severe pain and is prescribed morphine may benefit from a laxative like psyllium to help manage opioid-induced constipation. This situation would not necessarily require the nurse to question the order for psyllium.
Choice C rationale
A client who is post-operative and is on a clear liquid diet may experience constipation due to the low fiber content of the diet. However, this situation would not necessarily require the nurse to question the order for psyllium. Once the client progresses to a regular diet, psyllium can help add bulk to the stool and promote regular bowel movements.
Choice D rationale
This choice is correct. A client with a recent stroke who has difficulty swallowing may be at risk for aspiration, or the inhalation of food or liquid into the lungs, when taking psyllium. Psyllium is a bulk-forming laxative that absorbs water in the intestines to form a softer, bulkier stool. If a client with swallowing difficulties were to aspirate the psyllium, it could potentially expand in the lungs when it comes into contact with moisture, leading to serious complications. Therefore, the nurse should question the order for psyllium in this situation.