Exhibits
Review H and P, nurse's notes, flow sheet, and prescriptions.
Mark whether the assessment finding represents a therapeutic result of the lactulose administered, a non-therapeutic side-effect, or an unrelated finding. Each row must have only one option selected.
Reported slight rectal burning sensation
Large, soft stool
Dizziness
Pain level of 3 on a 0 to 10 pain scale
600ml of urine
Abdomen soft and flat
Respiratory rate 13 breaths/min
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"C"},"E":{"answers":"C"},"F":{"answers":"C"},"G":{"answers":"C"}}
- The reported slight rectal burning sensation after the administration of a bisacodyl suppository is likely a non-therapeutic side effect. This sensation is a common reaction to rectal medication administration and not directly related to the therapeutic effects of lactulose.
- A large, soft stool can be considered a therapeutic result of lactulose, which is often prescribed as a laxative to treat constipation. Its effectiveness is indicated by the production of soft stools.
- Dizziness experienced by the patient after requesting to use the restroom could be an unrelated finding or a non-therapeutic side effect. Given that morphine was administered, which can cause dizziness as a side effect, it is important to consider all medications and their interactions when assessing this symptom.
- A pain level of 3 on a 0 to 10 pain scale is an unrelated finding concerning the administration of lactulose. Pain assessment is subjective and can be influenced by various factors unrelated to lactulose treatment.
- The voiding of 600ml of urine is an unrelated finding to the lactulose treatment. Urine output is influenced by many factors, including fluid intake and other medications.
- An abdomen that is soft and flat is an unrelated finding to the lactulose treatment. This is a normal physical examination finding and does not directly correlate with the administration of lactulose.
- A respiratory rate of 13 breaths/min is also an unrelated finding to the lactulose treatment. The normal respiratory rate for an adult is typically between 12 to 20 breaths per minute.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.8"]
Explanation
Volume (mL) = Desired dose (mg) / Concentration (mg/mL)
In this case:
- Desired dose = 80 mg
- Concentration = 60 mg/0.6 mL
Plugging the values into the formula:
- Volume = 80 mg / (60 mg/0.6 mL) = 0.8 mL
Therefore, the nurse should administer 0.8 mL of enoxaparin sodium.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"C"},"G":{"answers":"C"}}
Explanation
1. Dizziness while sitting up: Non-therapeutic side effect
- Dizziness is a common side effect of minoxidil, often due to the vasodilatory effects, which can cause orthostatic hypotension.
2. Blood glucose 218 mg/dL: Unrelated finding
- Elevated blood glucose is unrelated to minoxidil administration and is more likely related to the client's diabetes.
3. Mouth dryness: Non-therapeutic side effect
- Dry mouth can be a side effect of minoxidil, though it is not a common one.
4. Blood pressure 162/111 mmHg: Therapeutic result
- The reduction in blood pressure from 203/166 mmHg to 162/111 mmHg is a therapeutic effect of minoxidil, which is used to lower blood pressure.
5. Heart rate 99: Non-therapeutic side effect
- Tachycardia can be a side effect of minoxidil, as it can lead to reflex tachycardia due to its vasodilatory effects.
6. Pain of 1 out of 10: Unrelated finding
- The reduction in pain is unrelated to the administration of minoxidil and is likely due to the ibuprofen given for pain management.
7. Urine output 600 mL: Unrelated finding
- Urine output is not directly related to the administration of minoxidil and is not typically affected by the drug.
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