Two months after taking nitrofurantoin for a bacterial infection, a client reports the onset of severe, watery diarrhea to the home care nurse. How should the nurse respond?

Determine if the full course of the initial prescription of medication was taken.

Explain that the diarrhea may be an adverse eﬀect that requires further evaluation.

Oﬀer instructions about the use of an over-the-counter antidiarrheal medication.

advise that the infection has returned, and additional medication will be needed.

Answer and Explanation

The Correct Answer is B

Nitrofurantoin is an antibiotic commonly used to treat urinary tract infections. One of the adverse eﬀects of nitrofurantoin is diarrhea, which may be severe and watery. Therefore, it is important for the home care nurse to inform the client that the diarrhea may be a side eﬀect of the medication and requires further evaluation. The nurse should instruct the client to stop taking the medication and contact their healthcare provider for further assessment and treatment. The nurse should also assess the client's ﬂuid and electrolyte status and monitor for signs of dehydration.

Option a is important to consider, but it does not address the potential adverse eﬀect of the medication.

Option c may be appropriate in some cases, but it is not the priority intervention at this time.

Option d is not necessarily true and may cause unnecessary alarm to the client.

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Correct Answer is B

Explanation

Lactulose is a medication commonly used in the management of hepatic encephalopathy. It works by reducing the absorption of ammonia in the gut, which is a toxin that can accumulate in the blood in patients with liver dysfunction.

Monitoring serum electrolytes and ammonia levels can help the nurse evaluate the eﬀectiveness of lactulose therapy. Elevated ammonia levels can indicate that the medication is not eﬀectively reducing ammonia absorption and may require adjustment in dose or frequency. Additionally, monitoring electrolyte levels can help detect any imbalances that may occur because of lactulose therapy.

Fingerstick glucose levels (option A) are not relevant to evaluating the therapeutic response of lactulose in hepatic encephalopathy.

Stool color and character (option C) may be monitored to assess the side eﬀects of lactulose, such as diarrhea, but are not the best assessments to evaluate therapeutic response.

Serum hepatic enzymes (option D) may be useful in assessing the severity of liver disease but are not the best assessment to evaluate the therapeutic response of lactulose in hepatic encephalopathy.

A. Use stool softener as needed. B. Avoid ingestion of alcohol. C. Discontinue when spasms cease. D. Take medication with meals.

Correct Answer is C

Explanation

Baclofen is a muscle relaxant medication used to treat muscle spasticity, which is a condition that causes muscles to become stiﬀ and rigid. It works by reducing the activity of nerves in the brain and spinal cord that cause muscle spasms.

Option a, using stool softener as needed, is appropriate because baclofen can cause constipation as a side eﬀect.

Option b, avoiding ingestion of alcohol, is also appropriate because alcohol can increase the sedative eﬀects of baclofen and cause drowsiness or dizziness.

Option d, taking medication with meals, is recommended because it can help reduce stomach upset and nausea that may occur as a side eﬀect of the medication.

Option c, discontinuing the medication when spasms cease, is incorrect because muscle spasticity is a chronic condition, and baclofen is used to manage symptoms over a prolonged period. Discontinuing the medication abruptly can cause withdrawal symptoms and exacerbate the spasticity. Therefore, the nurse should educate the client to take the medication as prescribed by the healthcare provider and not discontinue it without medical advice.

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Two months after taking nitrofurantoin for a bacterial infection, a client reports the onset of severe, watery diarrhea to the home care nurse. How should the nurse respond?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with hepatic encephalopathy is receiving lactulose. Which assessment provides the nurse with the nest information to evaluate the client’s therapeutic response to the drug?

Correct Answer is B

Explanation

A client with muscle spasticity receives a prescription for baclofen. Which information provided by the client requires additional instruction by the nurse?

Correct Answer is C

Explanation

The nurse is caring for a client who is taking diclofenac, an NSAID drug for rheumatoid arthritis. During a clinic visit, the client appears pale and reports increasing fatigue. Which of the client’s serum laboratory values is most important for the nurse to review?

Which nursing action had the highest priority when administering a dose of codeine with acetaminophen to a client?

A client is scheduled for a spiral computed topography (CT) scan with contrast to evaluate for pulmonary embolism. Which information in the client’s history requires follow-up by the nurse?

Which assessment data indicated to the nurse that a client is having an anaphylactic reaction to a medication?

A client with psychosis who is receiving an antipsychotic medication is continuously rubbing the back of the neck. Which nursing intervention is best for the nurse to implement?

A client taking atorvastatin becomes an increased serum creatine phosphokinase (CK) level. The nurse should assess the client for the onset of which problem?

The nurse assesses a client with intermittent claudication who is receiving pentoxifylline. Which assessment should the nurse perform to determine the eﬀectiveness of the medication?

A client who is taking albendazole reports experiencing fatigue, nausea, and dark urine. The nurse observes a yellowing of the client’s skin and sclera. Which lab results should the nurse review?