A nurse is caring for a client who refuses a prescribed influenza immunization. Which of the following actions should the nurse take first?
Ask the client to describe their concerns.
Contact the provider who prescribed the immunization.
Provide the client with education about the immunization.
Document the client’s refusal of the immunization.
The Correct Answer is A
Choice A rationale
Asking the client to describe their concerns allows the nurse to understand the client’s perspective and address any misconceptions or fears they may have about the influenza immunization.
Choice B rationale
Contacting the provider is important but should be done after understanding the client’s concerns to provide a comprehensive report.
Choice C rationale
Providing education is essential but should follow understanding the client’s specific concerns to tailor the information effectively.
Choice D rationale
Documenting the refusal is necessary but should be done after addressing the client’s concerns and providing education.
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Correct Answer is D
Explanation
Choice A rationale
Hyperglycemia is not a common adverse effect of colesevelam. Colesevelam is primarily used to lower cholesterol levels and can also help control blood sugar levels in patients with type 2 diabetes.
Choice B rationale
Stomatitis, or inflammation of the mouth, is not typically associated with colesevelam. This medication works in the intestines and is not absorbed into the bloodstream, so it does not commonly cause systemic side effects.
Choice C rationale
Fever is not a known adverse effect of colesevelam. The medication’s side effects are generally limited to the gastrointestinal system.
Choice D rationale
Constipation is a common adverse effect of colesevelam. This medication binds to bile acids in the intestines, which can lead to gastrointestinal side effects such as constipation.
Correct Answer is D
Explanation
Choice A rationale
Sucralfate should be taken on an empty stomach, not with meals, to ensure it coats the ulcer effectively.
Choice B rationale
There is no need to reduce dietary fiber while taking sucralfate. Fiber intake does not interfere with the medication’s effectiveness.
Choice C rationale
Antacids should not be taken within 30 minutes before or after taking sucralfate, as they can interfere with its action.
Choice D rationale
Increasing fluid intake is recommended while taking sucralfate to help prevent constipation, a common side effect of the medication.