Before administering a laxative to a bedfast client, it is most important for the nurse to perform which assessment?

Evaluate the client's ability to recognize the urge to defecate.

Determine the frequency and consistency of bowel movements.

Observe the skin integrity of the client's rectal and sacral areas.

Assess the client's strength in moving and turning in the bed.

Answer and Explanation

The Correct Answer is B

A) Evaluate the client's ability to recognize the urge to defecate: Assessing the client's ability to recognize the urge to defecate is important for promoting independence in toileting. However, this assessment may not directly indicate the need for administering a laxative. It is more relevant for clients who are able to ambulate or have control over their bowel movements.

B) Determine the frequency and consistency of bowel movements: Assessing the frequency and consistency of bowel movements provides valuable information about the client's bowel function and helps determine the need for a laxative. It allows the nurse to establish a baseline and evaluate the effectiveness of interventions. Understanding the client's typical bowel pattern is crucial before administering a laxative to avoid overmedication or potential complications such as diarrhea or fecal impaction.

C) Observe the skin integrity of the client's rectal and sacral areas: Assessing skin integrity in the rectal and sacral areas is crucial for preventing pressure ulcers, especially in bedfast clients. However, it is not directly related to the need for administering a laxative.

D) Assess the client's strength in moving and turning in the bed: While assessing the client's strength and mobility is important for overall care and prevention of complications related to immobility, it may not be directly related to the need for administering a laxative. This assessment is more relevant for preventing complications such as pressure ulcers and maintaining musculoskeletal function.

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Correct Answer is D

Explanation

A) Holding the dose of IV pantoprazole until the client has finished eating breakfast may delay the onset of action of the medication, as pantoprazole is typically administered before meals to maximize its effectiveness in reducing gastric acid secretion. Additionally, delaying the dose may not provide immediate relief for the client's he’rtburn symptoms.

B) Providing a PRN dose of antacid along with the scheduled medications may temporarily relieve the client's he’rtburn symptoms, but it does not address the underlying cause of peptic ulcer disease or prevent further gastric acid secretion, which is the primary goal of pantoprazole and sucralfate administration.

C) Instructing the client to take the dose of sucralfate PO while eating breakfast may interfere with the optimal absorption of the medication. Sucralfate forms a protective barrier over ulcers in the stomach and should be administered on an empty stomach to allow it to adhere to the gastric mucosa effectively.

D) Administering both of the medications before breakfast as scheduled is the most appropriate action. Pantoprazole is a proton pump inhibitor that reduces gastric acid production, and sucralfate forms a protective barrier over ulcers in the stomach. Administering these medications before breakfast allows them to work synergistically to reduce gastric acid secretion and protect the gastric mucosa, helping to alleviate the client's he’rtburn symptoms and promote ulcer healing.

A. Measure the client’s vital signs. B. Obtain a fingerstick blood glucose. C. Perform a neurological exam. D. Administer glucagon intramuscularly (IM).

Correct Answer is B

Explanation

A) While measuring the client’s vital signs is a routine nursing intervention, the reported symptoms of confusion and blurred vision after receiving glipizide suggest the possibility of hypoglycemia. Vital signs may not provide immediate information about the client’s glucose levels or help confirm hypoglycemia. However, if the client’s symptoms persist or worsen, assessing vital signs becomes important to monitor for signs of shock or other complications.

B) Obtaining a fingerstick blood glucose is the priority action in this situation. Glipizide is an oral antidiabetic medication that stimulates insulin release from the pancreas, leading to lower blood glucose levels. Symptoms such as confusion and blurred vision are indicative of hypoglycemia, a potential adverse effect of glipizide. Checking the client’s blood glucose level will confirm hypoglycemia and guide further interventions.

C) While performing a neurological exam may be warranted if the client’s symptoms persist or if there are concerns about other neurological issues, confirming hypoglycemia with a fingerstick blood glucose test should be the immediate priority.

D) Administering glucagon intramuscularly (IM) is indicated for severe hypoglycemia when the client is unconscious or unable to swallow. However, in this scenario, the client is conscious and able to report symptoms. Before administering glucagon, it is essential to confirm hypoglycemia with a blood glucose measurement to avoid unnecessary interventions.

Therefore, the nurse should promptly obtain a fingerstick blood glucose to confirm hypoglycemia and initiate appropriate treatment for the client’s symptoms.

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Before administering a laxative to a bedfast client, it is most important for the nurse to perform which assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with peptic ulcer disease (PUD) 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?

Correct Answer is D

Explanation

A client reports confusion and blurred vision after receiving a dose of glipizide. Which action should the nurse implement?

Correct Answer is B

Explanation

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