A nurse is preparing to administer lactulose 30 g PO four times daily to a client who has portal-systemic encephalopathy. The amount available is lactulose al solution 10 g/15 ml. How many ml. should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero)

A. Cleansing the insertion site daily: Frequent cleansing of an epidural insertion site is not recommended because excessive manipulation increases the risk of infection. Standard practice is to keep the site clean and dry, assessing it regularly without daily cleaning unless contamination occurs.

B. Covering the insertion site with a transparent dressing: Using a sterile, transparent dressing allows continuous visualization of the insertion site for early signs of infection, leakage, or inflammation. It protects the site while permitting ongoing assessment, which is essential for clients receiving epidural analgesia.

C. Administering supplemental opioids as needed: Supplemental opioids should be used cautiously in clients with epidural analgesia because they can increase the risk of respiratory depression and sedation. Pain management should primarily rely on the epidural infusion and follow prescribed protocols rather than routine PRN systemic opioids.

D. Replacing the infusion tubing every 72 hr: Epidural infusion tubing typically should be replaced according to institutional protocol, often every 24 hours, not 72 hours, to reduce the risk of infection. Extending tubing changes beyond recommended intervals increases the likelihood of contamination and catheter-related complications.

Rationale for correct choices

• Peritonitis: The child exhibits classic signs of an inflamed and potentially perforated appendix, including worsening abdominal pain, right lower quadrant tenderness, firm and distended abdomen, hypoactive bowel sounds, fever, and elevated WBC and CRP. These signs indicate localized inflammation that can progress to peritonitis if untreated.

• Perforated appendix: The child’s sudden improvement in pain followed by worsening distention and hypoactive bowel sounds suggests a possible appendix perforation. Laboratory findings of leukocytosis and elevated inflammatory markers support significant infection. Perforation allows intestinal contents to enter the peritoneal cavity, directly causing peritonitis.

Rationale for incorrect choices

• Pneumonia: The child has occasional expiratory wheezing, but lung sounds are not abnormal and oxygen saturation is normal. There are no signs of cough, increased respiratory rate, or infiltrates on imaging that would suggest pneumonia. Respiratory involvement is minor and does not account for the acute abdominal findings.

• Dehydration: While nausea, vomiting, and NPO status may contribute to fluid loss, the child’s vital signs do not indicate severe dehydration. Blood pressure is within normal range and perfusion appears adequate. Dehydration is a secondary concern and not the most immediate risk compared with peritonitis.

• Ileus: Hypoactive bowel sounds could suggest an ileus; however, the firm, distended abdomen and systemic inflammatory markers point toward an acute surgical complication rather than simple postoperative or functional ileus. The underlying cause is likely perforation, making ileus a secondary manifestation.

• Anxiety: The child expresses fear, but anxiety is not the primary clinical concern driving risk. Psychological distress is present but does not explain the acute abdominal findings or the elevated WBC and CRP. Anxiety management is supportive rather than emergent.

• Client statement: Statements of pain or fear provide important subjective data but do not identify the physiological cause of risk. While the child reports worsening symptoms, the primary risk arises from the anatomical and infectious changes due to appendix perforation.

• Bowel sounds: Hypoactive bowel sounds indicate reduced intestinal activity but are a secondary finding. They reflect the impact of peritoneal inflammation rather than the underlying cause, which is the perforated appendix. Monitoring bowel sounds helps assess progression but does not define the main risk.

• Lung sounds: Lung sounds are clear, indicating no pulmonary complication. The respiratory system is not involved in the current risk profile. Focus should remain on the abdominal pathology causing systemic inflammation.

• Nausea and vomiting: These symptoms are expected with appendicitis and contribute to discomfort and fluid imbalance but are not the primary factor placing the child at highest risk. The risk stems from anatomical perforation leading to peritoneal contamination.