A patient with liver failure has been admitted with hepatic encephalopathy and is prescribed lactulose every 2 hours. The patient is currently oriented and has had 6 loose, watery stools since 0700.
The 1400 dose of lactulose is due.
What should be the nurse’s next course of action?
No action is required as this is the desired therapeutic effect.
Withhold the dose and contact the doctor for daily stool count parameters.
Administer the medication since diarrhea is a common side effect.
Remove fall precautions due to changes in mental status.
The Correct Answer is A
Choice A rationale
Lactulose is used to treat hepatic encephalopathy, a condition that affects patients with liver failure. It works by reducing the absorption of ammonia in the gut. Having loose, watery stools is a desired therapeutic effect of lactulose. Therefore, no action is required if the patient is oriented and has had 6 loose, watery stools since 07007.
Choice B rationale
Withholding the dose and contacting the doctor for daily stool count parameters is not necessary in this situation. The patient is currently oriented, which suggests that the lactulose is effectively managing their hepatic encephalopathy.
Choice C rationale
Administering the medication because diarrhea is a common side effect is not the correct course of action. The presence of loose, watery stools is not merely a side effect, but a desired therapeutic effect of lactulose in the treatment of hepatic encephalopathy.
Choice D rationale
Removing fall precautions due to changes in mental status is not necessary in this situation. The patient is currently oriented, which suggests that the lactulose is effectively managing their hepatic encephalopathy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Amoxicillin is a type of penicillin, and if a client has had a rash or any other allergic reaction to penicillin in the past, it’s possible they could have a similar reaction to amoxicillin. Therefore, the nurse should discuss with the provider the possibility of using a different antibiotic. This is important because allergic reactions to antibiotics can be severe and even life-threatening.
Choice B rationale
Administering the amoxicillin and keeping epinephrine on hand is not the best course of action. While epinephrine can be used to treat severe allergic reactions, it’s better to avoid the risk of an allergic reaction in the first place if possible.
Choice C rationale
Requesting the provider to prescribe an antihistamine would not address the potential for a serious allergic reaction to the amoxicillin. Antihistamines can help with mild allergic reactions, but they may not be sufficient for a severe reaction.
Choice D rationale
Asking for an order for a beta-lactamase resistant drug might not be necessary. Beta-lactamase resistant drugs are used to treat infections caused by bacteria that produce beta-lactamase, an enzyme that can break down and resist penicillins. However, the client’s allergy to penicillin does not necessarily mean that a beta-lactamase resistant drug is required.
Correct Answer is D
Explanation
Choice A rationale
While older age and the use of certain medications can increase the risk of developing drug- resistant tuberculosis, these factors alone do not pose the greatest risk.
Choice B rationale
The presence of a red-orange color in the urine after being treated with rifampin is a common side effect of the medication and does not indicate an increased risk of developing drug- resistant tuberculosis.
Choice C rationale
A patient who has been taking rifampin and isoniazid as prescribed for 24 months is not at the greatest risk of developing drug-resistant tuberculosis. Adherence to the prescribed treatment regimen is actually crucial in preventing the development of drug-resistant strains of the disease.
Choice D rationale
A patient who did not complete the full course of anti-tubercular therapy in the past is at the greatest risk of developing a drug-resistant form of the disease. Incomplete treatment can allow tuberculosis bacteria to develop resistance to the medications used, leading to the emergence of drug-resistant strains.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.