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 ["14"]
Explanation
To calculate the infusion rate in drops per minute (gtt/min), we can use the following formula: Infusion rate (gtt/min) = (Volume to be infused (ml) * Drop factor) / Time (min) Given:
Volume to be infused: 1000 ml
Drop factor: 10 gtt/ml
Time: 12 hr
First, we need to convert the time from hours to minutes:
12 hr * 60 min/hr = 720 min
Now, we can calculate the infusion rate:
Infusion rate (gtt/min) = (1000 ml * 10 gtt/ml) / 720 min
Simplifying the equation:
Infusion rate (gtt/min) = 10000 gtt / 720 min
Dividing both sides:
Infusion rate (gtt/min) ≈ 13.89 gtt/min
Rounding the answer to the nearest whole number, the nurse should set the manual IV infusion to deliver approximately 14 gtt/min.
Correct Answer is C
Explanation
The left Sims' position (also known as the left lateral position) is the appropriate position for administering a soapsuds enema. This position allows for better visualization and access to the rectum and facilitates the flow of the enema solution.
The other options mentioned are incorrect:
Inserting the tubing about 15 cm (6 in) into the anus: The specific depth of insertion may vary depending on the client, but the general guideline is to insert the tubing about 3 to 4 inches into the rectum for an adult. 15 cm (6 in) would be excessively deep and could cause discomfort or injury.
Hanging the enema container 61 cm (24 in) above the anus: The height at which the enema container is hung should be no more than 18-24 inches (45-60 cm) above the anus. Hanging it too high can cause excessive pressure and discomfort during the administration.
Putting on sterile gloves: Sterile gloves are not typically required for the administration of a soapsuds enema. Clean gloves or non-sterile gloves are generally sufficient for this procedure.
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