The client with irritable bowel disease (IBD) is prescribed sulfasalazine, a sulfonamide antibiotic. Which intervention should the nurse implement when administering the medication?
Explain that the medication may cause bruising.
Ensure the client drinks at least 2000 mL of water daily.
Administer the medication once a day before breakfast.
Assess the client's stool for steatorrhea and mucus.
The Correct Answer is B
Choice A rationale
Sulfasalazine is more commonly associated with side effects such as gastrointestinal discomfort and hypersensitivity reactions, rather than causing bruising. Monitoring for bruising is not a specific intervention for this medication.
Choice B rationale
Ensuring the client drinks at least 2000 mL of water daily helps prevent crystal formation in the kidneys, a potential side effect of sulfasalazine. Adequate hydration also supports overall renal function and reduces the risk of kidney stones.
Choice C rationale
Sulfasalazine is usually taken multiple times a day with meals to reduce gastrointestinal side effects and improve absorption. Administering it once a day before breakfast is not the typical dosing schedule.
Choice D rationale
While it is important to monitor the client's stool, steatorrhea (fatty stools) and mucus are not specifically associated with sulfasalazine. The primary focus is on ensuring hydration and monitoring for other side effects such as rash and gastrointestinal discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Excess fluid volume: intravascular is less relevant as it is more associated with conditions such as heart failure rather than bowel obstruction. Fluid shifts in bowel obstruction usually lead to third-spacing rather than intravascular volume excess.
Choice B rationale
Risk for ineffective tissue perfusion: gastrointestinal is correct as bowel obstruction can compromise blood flow to the intestines, leading to ischemia and necrosis. This is a critical concern that needs to be monitored and managed promptly.
Choice C rationale
Risk for infection is a valid concern but not the primary issue compared to tissue perfusion risks. Infection risk typically becomes more prominent if there are signs of bowel perforation or necrosis.
Choice D rationale
Acute pain assessment is important but is an aspect of managing the current problem rather than listing the primary problem itself. Pain management should follow once the main problem has been identified.
Correct Answer is D
Explanation
Choice A rationale
Increasing the IV fluid flow rate is a critical task requiring clinical judgment and should not be delegated to an unlicensed nursing assistant. This task involves assessing the patient's hemodynamic status and fluid balance, which requires nursing expertise.
Choice B rationale
Listening to breath sounds in all lung fields is an assessment task that requires nursing knowledge and skills. It involves identifying normal and abnormal breath sounds, which is outside the scope of practice for an unlicensed nursing assistant.
Choice C rationale
Checking the abdominal dressing for bleeding is an assessment and monitoring task. It involves evaluating the wound site for signs of hemorrhage or infection, which requires nursing assessment skills.
Choice D rationale
Documenting the amount of output on the I&O sheet is a task that can be delegated to an unlicensed nursing assistant. This task involves recording measurements, which does not require clinical judgment and is within the assistant's scope of practice.
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