A nurse is caring for a client who has cirrhosis and a prescription for lactulose. Following administration, the nurse should monitor the client for which of the following adverse effects?
Peripheral edema
Diarrhea
Dry mouth
Headache
The Correct Answer is B
After administering lactulose to a client with cirrhosis, the nurse should monitor for the adverse effects of diarrhea. Lactulose is a laxative commonly used in the treatment of hepatic encephalopathy, which can occur in individuals with cirrhosis. One of the intended effects of lactulose is to promote bowel movements and reduce the absorption of ammonia in the gut, thus helping to manage hepatic encephalopathy.
While lactulose can cause adverse effects such as diarrhea, it is not typically associated with peripheral edema. Peripheral edema is often seen in cirrhosis due to fluid retention caused by liver dysfunction.
Dry mouth and headache are less commonly associated with lactulose use and are not typically the primary adverse effects to monitor for in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
When collecting a urine specimen via straight catheterization, it is important to use a sterile specimen container to maintain the integrity of the sample and prevent contamination. Using a non-sterile container can introduce bacteria and affect the accuracy of the culture and sensitivity results.
The other options mentioned are incorrect:
Using sterile water to inflate the balloon: This action is relevant when inflating the balloon of an indwelling urinary catheter, but in a straight catheterization, there is no balloon involved.
Instructing the client to clean from front to back with an antiseptic solution: This instruction is appropriate for cleaning the urethral meatus before inserting an indwelling urinary catheter, but in a straight catheterization, the nurse performs the procedure using sterile technique and does not require the client to clean themselves.
Collecting urine from the catheter's port: In a straight catheterization, the nurse collects urine directly from the catheter tube using a sterile syringe or collection container, rather than from a separate port.
Correct Answer is A,B,C,D,E
Explanation
When removing personal protective equipment (PPE) after caring for a client in contact isolation, the nurse should follow the steps in the following order:
1. Remove gloves.
2. Remove protective eyewear.
3. Remove gown.
4. Remove mask.
5. Perform hand hygiene.
By following this sequence, the nurse ensures that the removal of PPE is done in a way that minimizes the risk of contamination. Removing gloves first helps prevent the spread of potential contaminants on the hands. Removing protective eyewear next avoids any potential contact with the face or eyes during the removal process. Removing the gown comes next, followed by the mask. Lastly, performing hand hygiene after removing all PPE helps ensure the hands are thoroughly cleaned.
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