The nurse is administering sucralfate to a client with stomatitis secondary to chemotherapy. The client wants to take the medication after breakfast. How should the nurse respond?

Allow the client to take the medication up to 1 hour after breakfast.

Instruct the client to take it when the meal tray is delivered.

Document the client's refusal of the medication at this time.

Explain the need to take the medication at least 1 hour before meals.

Answer and Explanation

The Correct Answer is D

A) Allow the client to take the medication up to 1 hour after breakfast:
Administering sucralfate up to 1 hour after breakfast may not provide optimal effectiveness as it should ideally be taken on an empty stomach to form a protective barrier over irritated areas in the stomach and intestines before food intake. Taking it after breakfast might not allow sufficient time for the medication to coat these areas adequately.

B) Instruct the client to take it when the meal tray is delivered:
Taking sucralfate with meals or when the meal tray is delivered is not recommended as food can interfere with its effectiveness. It is best taken on an empty stomach to allow it to coat the stomach lining without interference from food, ensuring maximum therapeutic benefit.

C) Document the client's refusal of the medication at this time:
Documenting a refusal should only be done if the client declines after receiving appropriate education and understanding. Simply refusing the client's request without providing education on the proper timing for taking sucralfate would not be appropriate.

D) Explain the need to take the medication at least 1 hour before meals:
This is the correct response. Educating the client about the importance of taking sucralfate at least 1 hour before meals ensures optimal effectiveness. This timing allows the medication to form a protective barrier over irritated areas in the stomach and intestines before food intake, maximizing its therapeutic benefit.

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Correct Answer is C

Explanation

A) Serum ammonia level of 30 pg/dl (17.62 μmol /dL): Serum ammonia level is not directly affected by sodium polystyrene sulfonate administration. Ammonia levels are typically related to liver function and are not relevant in assessing the effectiveness of this medication for hyperkalemia.
B) Serum glucose level of 120 mg/dL (6.7 mmol/L): Serum glucose level is unrelated to the action of sodium polystyrene sulfonate. While hyperkalemia can sometimes lead to glucose metabolism abnormalities, the glucose level alone does not provide information about the medication's effectiveness.
C) Serum potassium level of 3.8 mEq/L (3.8 mmol/L): Sodium polystyrene sulfonate, also known as Kayexalate, is a medication used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestines, leading to potassium excretion through feces. A decrease in serum potassium level within the normal range indicates that the medication has been effective in lowering potassium levels, which is the intended therapeutic outcome in the context of treating hyperkalemia associated with acute kidney injury (AKI).
D) Hemoglobin level of 13.5 g/dL (135 g/L): Hemoglobin level is unrelated to the action of sodium polystyrene sulfonate. It reflects the oxygen-carrying capacity of red blood cells and is not directly influenced by potassium-lowering medications.

A. Keep an oral liquid or glucose source available. B. Check blood glucose levels every six hours. C. Assess for hypoglycemia between meals. D. Provide meals at the same time this insulin is given.

Correct Answer is D

Explanation

A) Keep an oral liquid or glucose source available:
While it's essential to have a readily available source of glucose in case of hypoglycemia, ensuring consistency in meal timing is more critical for managing blood sugar levels in clients receiving insulin lispro. However, having a glucose source available is still important as a precautionary measure.

B) Check blood glucose levels every six hours:
Frequent monitoring of blood glucose levels is essential in managing diabetes, but checking levels every six hours may not be necessary for all clients. The frequency of blood glucose monitoring should be individualized based on factors such as the client's overall glycemic control, insulin regimen, meal timing, and activity level.

C) Assess for hypoglycemia between meals:
While assessing for hypoglycemia is important, especially in clients receiving insulin therapy, ensuring consistent meal timing is a more proactive measure to prevent hypoglycemia. Clients should ideally consume meals or snacks containing carbohydrates around the same time they administer rapid-acting insulins like insulin lispro to prevent blood sugar fluctuations.

D) Provide meals at the same time this insulin is given:
This is the correct intervention. Insulin lispro is a rapid-acting insulin that is typically administered just before meals to control postprandial blood sugar levels effectively. Providing meals at consistent times relative to insulin administration helps synchronize the peak action of the insulin with the rise in blood glucose that occurs after eating, minimizing the risk of hypoglycemia and hyperglycemia.

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The nurse is administering sucralfate to a client with stomatitis secondary to chemotherapy. The client wants to take the medication after breakfast. How should the nurse respond?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Which intervention is most important for the nurse to implement for a client with type 2 diabetes mellitus (DM) who is receiving insulin lispro?

Correct Answer is D

Explanation

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