A nurse is caring for a patient on the medical unit. A client has developed hepatic encephalopathy secondary to cirrhosis. The client's current medication regimen includes lactulose four times daily. What desired outcome should the nurse relate to this pharmacologic intervention?

Two to three soft bowel movements daily

Significant increase in appetite and food intake

Absence of nausea and vomiting

Absence of blood or mucus in stool

Answer and Explanation

The Correct Answer is A

A. Lactulose works by reducing the absorption of ammonia in the intestines, a key factor in hepatic encephalopathy. The desired effect is two to three soft stools per day, which helps eliminate ammonia.
B. Lactulose does not directly affect appetite or food intake.
C. Although gastrointestinal symptoms may improve, lactulose is not used to treat nausea and vomiting.
D. Lactulose is not indicated for treating or preventing gastrointestinal bleeding or mucus in the stool.

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Correct Answer is B

Explanation

A. Monitoring for dysrhythmias is important, especially due to potential electrolyte shifts, but it is secondary to stabilizing perfusion and hydration.
B. Maintaining and monitoring fluid balance is the top priority in the initial management of diabetic ketoacidosis (DKA) because clients are severely dehydrated due to osmotic diuresis. Prompt fluid resuscitation is essential to restore perfusion and support metabolic correction.
C. Assessing level of consciousness is necessary, especially if cerebral edema is a concern, but it follows after fluid and metabolic stabilization.
D. Venous thromboembolism is a risk in critically ill patients, but it is not an immediate priority in the acute phase of DKA treatment.

A. Mobilization with assistance at least 4 times daily B. Administration of beta-adrenergic blockers as prescribed C. Vitamin B12 injections as prescribed D. Administration of diuretics as prescribed

Correct Answer is D

Explanation

A. Mobilization is important but not the primary intervention for ascites.
B. Beta-blockers are used to manage portal hypertension but are not the first priority in ascites management.
C. Vitamin B12 injections are unrelated to ascites.
D. Diuretics help reduce fluid accumulation by promoting sodium and water excretion, which is essential in managing ascites.

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A nurse is caring for a patient on the medical unit. A client has developed hepatic encephalopathy secondary to cirrhosis. The client's current medication regimen includes lactulose four times daily. What desired outcome should the nurse relate to this pharmacologic intervention?

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Naxlex Comprehensive Predictor Exams

A client with a history of type 1 diabetes has just been admitted to the critical care unit (CCU) for diabetic ketoacidosis. The CCU nurse should prioritize what assessment during the client's initial phase of treatment?

Correct Answer is B

Explanation

A nurse is amending a client's plan of care in light of the fact that the client has recently developed ascites. What should the nurse include in this client's care plan?

Correct Answer is D

Explanation

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