Lactulose was prescribed two days ago for a client who was recently diagnosed with hepatic encephalopathy. The client is confused and experiencing frequent loose stools. Laboratory findings show an elevated serum ammonia (NH) level of 220 μg/dL (157.1 μmol/dL). Which action should the nurse take?

Reference Range:

Ammonia [10 to 80 μg/dL (6 to 47 μmol/L)]

Hold the next dose of lactulose.

Continue the prescribed dose of lactulose.

Replace total volume voided with oral or IV fluids.

Report the number of diarrhea stools to the healthcare provider (HCP).

Answer and Explanation

The Correct Answer is B

B. Lactulose works by acidifying the colonic contents, which promotes the conversion of ammonia (NH3) to ammonium (NH4+). Ammonium is less readily absorbed from the colon into the bloodstream, reducing systemic ammonia levels. This action helps alleviate the neurotoxic effects of ammonia on the brain, thereby improving neurological symptoms associated with hepatic encephalopathy.
A. Lactulose is required in clients with hepatic encephalopathy to excrete ammonia lowering its levels in blood. Holding the lactulose dose is inappropriate as the client’s ammonia levels are still high
C. Rehydrating the clients to replace lost fluids in the loose stools is important but does not address
the client’s elevated ammonia levels which may be exacerbating the client’s encephalopathy.
D. Reporting the number of diarrhea stools to the healthcare provider is important for ongoing assessment and management of the client's condition. However, it does not address the clients high ammonia levels.

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Free Nursing Study Resources

Correct Answer is ["A","C","E"]

Explanation

A. Standard precautions should always be followed when caring for any patient to prevent the transmission of infectious agents. Additionally, wearing a mask can provide further protection, especially if there is a risk of respiratory droplet transmission.
C. Culturing the wound drainage allows for the identification of the specific bacteria causing the infection, including whether it is methicillin-resistant Staphylococcus aureus (MRSA). Sensitivity testing helps determine which antibiotics are effective against the bacteria, guiding appropriate antibiotic therapy.
E. Contact precautions are necessary for preventing the transmission of MRSA to other patients, staff, and visitors. This includes wearing gloves and gowns when providing care, as well as ensuring proper hand hygiene practices. Visitors may also need to follow specific precautions to prevent the spread of infection.
B. While monitoring the client's white blood cell count may be important for assessing the body's response to infection, it is not specific to MRSA infection. MRSA infection is typically diagnosed based on clinical presentation and confirmed through laboratory tests such as wound cultures.
D. A low bacteria diet is not typically indicated for MRSA infection. MRSA is primarily treated with antibiotics, and dietary modifications are not a standard part of its management.

Correct Answer is ["1.6"]

Explanation

To determine how many milliliters (mL) of diazepam the nurse should administer to the client, first, we need to calculate the amount of medication needed for each dose.

The prescribed dose is 8 mg of diazepam.

Volume= Desired dose/available concentration per ml

Available concentration per ml= 10mg/2ml Available concentration per ml= 5mg/ml Volume= 8mg/5mg per ml

Volume= 1.6ml

So, the nurse should administer 1.6 mL of diazepam to the client.

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Naxlex Comprehensive Predictor Exams

A client with draining skin lesions of the lower extremity is admitted with possible methicillin resistant Staphylococcus aureus (MRSA). What nursing intervention (s) should the nurse include in the plan of care? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

Correct Answer is ["1.6"]

Explanation

A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make?

The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?

In providing discharge teaching to a client with chronic obstructive pulmonary disease (COPD), which instruction is most important for the nurse to emphasize?

An older adult client with symptoms of osteoarthritis asks the nurse which form of exercise would be most beneficial. Which is the best response by the nurse?

While caring for a client with full thickness burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before reporting this finding to the healthcare provider, the nurse should evaluate which laboratory value?

The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private room with airborne precautions pending diagnostic test results. Which diagnostic test should the nurse review to confirm the diagnosis of TB?

The nurse calls the healthcare provider because a client diagnosed with an abdominal aortic aneurysm (AAA) is reporting low back pain. Which additional information about the client would be important for the nurse to tell the healthcare provider?