A client who has advanced cirrhosis is receiving lactulose. Which finding by the nurse indicates that the medication is effective?
The client denies nausea or anorexia.
The client's bilirubin level decreases.
The client is alert and oriented.
The client has at least one stool daily.
The Correct Answer is C
A. The client denies nausea or anorexia: While improved appetite is beneficial, it does not directly indicate that lactulose is effective. Lactulose is primarily used to reduce ammonia levels and prevent hepatic encephalopathy. Symptom relief alone does not confirm therapeutic effect.
B. The client's bilirubin level decreases: Lactulose does not directly affect bilirubin levels. Bilirubin reflects liver excretory function, not the medication’s action on ammonia. Changes in bilirubin are not a reliable measure of lactulose effectiveness.
C. The client is alert and oriented: Lactulose reduces blood ammonia by promoting its excretion via the gastrointestinal tract. Improved mental status, such as being alert and oriented, indicates effective reduction of ammonia and prevention of hepatic encephalopathy.
D. The client has at least one stool daily: While increased bowel movements are expected with lactulose, the frequency alone does not confirm that ammonia levels are adequately reduced. Stool output is a mechanism, not the ultimate therapeutic outcome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Inspiratory crackles: Crackles indicate fluid accumulation in the lungs, often seen in cardiogenic or hypovolemic issues, not neurogenic shock. Pulmonary findings are not characteristic of neurogenic shock.
B. Temp. 101.2 F: Fever suggests infection or inflammatory processes, which are not defining features of neurogenic shock. Temperature elevation does not help confirm the presence of neurogenic shock.
C. Cool, clammy skin: Neurogenic shock typically causes vasodilation, leading to warm, dry skin rather than cool, clammy skin. Cool, clammy skin is more associated with hypovolemic or cardiogenic shock.
D. Heart rate 48 bpm: Bradycardia is a hallmark of neurogenic shock due to unopposed parasympathetic activity following spinal cord injury. Along with hypotension and vasodilation, bradycardia helps confirm the diagnosis. This vital sign is key in differentiating it from other shock types.
Correct Answer is A
Explanation
A. right-sided tension pneumothorax: Tracheal deviation away from the affected side, hypotension, tachycardia, and tachypnea are classic signs of tension pneumothorax. Since the trachea deviates to the left, the problem is on the right side. This is a life-threatening emergency requiring immediate decompression.
B. fall chest with sternal involvement: Flail chest from sternal or rib fractures causes paradoxical chest movement and respiratory distress, but tracheal deviation is not a typical finding. Hypotension may occur with associated injuries, but it does not explain the observed tracheal shift.
C. left-sided tension pneumothorax: A left-sided tension pneumothorax would push the trachea to the right, not to the left. The direction of tracheal deviation helps localize the affected side. This does not match the client’s presentation.
D. fractured ribs with splinting of the chest wall: Rib fractures can cause pain and shallow breathing, but they rarely cause tracheal deviation or severe hypotension. Splinting alone does not account for the hemodynamic instability or mediastinal shift seen in tension pneumothorax.
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