A patient with hepatic encephalopathy is receiving lactulose.
Which assessment provides the nurse with the best information to evaluate the patient’s therapeutic response to the drug?

Stool color and character.

Fingerstick glucose.

Serum electrolytes and ammonia.

Serum hepatic enzymes.

Answer and Explanation

The Correct Answer is C

Choice A rationale

While changes in stool color and character can be indicative of various health conditions, they are not the best indicators of a patient’s therapeutic response to lactulose in the context of hepatic encephalopathy.

Choice B rationale

Fingerstick glucose monitoring is important in managing conditions like diabetes, but it does not provide the best information to evaluate a patient’s therapeutic response to lactulose in the context of hepatic encephalopathy.

Choice C rationale

Lactulose is used in the management of hepatic encephalopathy, a condition that can occur in patients with severe liver disease. It works by reducing the absorption of ammonia in the gut, which is a toxin that can accumulate in the blood in patients with liver dysfunction. Therefore, monitoring serum electrolytes and ammonia levels can help evaluate the effectiveness of lactulose therapy.

Choice D rationale

While monitoring serum hepatic enzymes can provide valuable information about liver function, it does not provide the best information to evaluate a patient’s therapeutic response to lactulose in the context of hepatic encephalopathy.

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Correct Answer is D

Explanation

Choice A rationale

Eye drops for glaucoma are not typically used for long-term control of pain and swelling.

Choice B rationale

Restoring a smaller angle is not the goal of treatment for open-angle glaucoma.

Choice C rationale

While reducing excess pressure is a goal of glaucoma treatment, eye drops are typically used for long-term control rather than a temporary reduction of pressure.

Choice D rationale

Eye drops for open-angle glaucoma are used for long-term control of normal eye pressure. They need to be used every day, and depending on the type of medicine, may need to be used once, twice, or up to 4 times a day.

A. Suggest the patient to reduce the dosage of the medication. B. Check the patient’s capillary glucose level. C. Use a pulse oximeter to assess the patient’s oxygen saturation. D. Report the observation to the healthcare provider.

Correct Answer is D

Explanation

Choice A rationale

While reducing the dosage of a medication might be appropriate in some cases, it’s not the best initial action when a patient’s skin appears yellow. Yellowing of the skin, or jaundice, can be a sign of liver damage, which can be a serious side effect of acetaminophen. The healthcare provider should be notified before any changes are made to the medication regimen.

Choice B rationale

Checking the patient’s capillary glucose level would not be the most appropriate response to the observation of yellow skin. While it’s important to monitor glucose levels in patients with certain conditions, such as diabetes, it would not provide information about potential liver damage, the likely cause of the patient’s yellow skin.

Choice C rationale

Using a pulse oximeter to assess the patient’s oxygen saturation would not provide information about the cause of the patient’s yellow skin. While it’s an important assessment in many situations, it would not help in identifying potential liver damage from acetaminophen use.

Choice D rationale

This is the most appropriate action. Yellowing of the skin can be a sign of liver damage, a potential side effect of acetaminophen. The healthcare provider should be notified of this observation as soon as possible for further evaluation and management.

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A patient with hepatic encephalopathy is receiving lactulose.Which assessment provides the nurse with the best information to evaluate the patient’s therapeutic response to the drug?

Nursing Test Bank

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A patient with hepatic encephalopathy is receiving lactulose.
Which assessment provides the nurse with the best information to evaluate the patient’s therapeutic response to the drug?