A client with hepatic encephalopathy is receiving lactulose. Which assessment provides the nurse with the best information to evaluate the client's therapeutic response to the drug?
Stool color and character.
Serum electrolytes and ammonia.
Serum hepatic enzymes.
Fingerstick glucose.
The Correct Answer is B
Choice A reason: This is not the best assessment for the nurse to use to evaluate the client's therapeutic response to lactulose. Stool color and character may change as a result of lactulose administration, as it is a laxative that lowers the pH of the colon and promotes the excretion of ammonia. However, these changes are not indicative of the effectiveness of lactulose in reducing the ammonia levels in the blood, which is the main goal of the therapy.
Choice B reason: This is the best assessment for the nurse to use to evaluate the client's therapeutic response to lactulose. Serum electrolytes and ammonia are directly affected by lactulose administration, as it lowers the blood ammonia levels by converting it to ammonium and facilitating its elimination in the stool. The nurse should monitor the serum electrolytes and ammonia levels regularly to assess the efficacy and safety of lactulose therapy, as well as to adjust the dosage as needed.
Choice C reason: This is not the best assessment for the nurse to use to evaluate the client's therapeutic response to lactulose. Serum hepatic enzymes are markers of liver function and damage, and they may be elevated in clients with hepatic encephalopathy due to cirrhosis or other liver disorders. However, lactulose does not affect the hepatic enzymes directly, and it does not reverse the underlying liver disease. The nurse should monitor the serum hepatic enzymes to assess the progression and severity of the liver condition, but not to evaluate the response to lactulose.
Choice D reason: This is not the best assessment for the nurse to use to evaluate the client's therapeutic response to lactulose. Fingerstick glucose is a measure of blood glucose levels, and it may be altered in clients with hepatic encephalopathy due to impaired glucose metabolism by the liver. However, lactulose does not affect the blood glucose levels directly, and it does not improve the liver's ability to regulate glucose. The nurse should monitor the fingerstick glucose to assess the risk of hypoglycemia or hyperglycemia, but not to evaluate the response to lactulose.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: Using the eye drops until the excess pressure is reduced is not an accurate response, as it implies that the eye drops are only a temporary treatment. Open-angle glaucoma is a chronic condition that causes increased pressure in the eye due to impaired drainage of the aqueous humor. The eye drops are used to lower the eye pressure and prevent further damage to the optic nerve. The client will need to use the eye drops for the rest of their life, unless the healthcare provider advises otherwise.
Choice B reason: Using the eye drops for long-term control of pain and swelling is not an accurate response, as it does not address the main goal of the treatment. Open-angle glaucoma does not usually cause pain or swelling, as the pressure builds up gradually and painlessly. The eye drops are used to lower the eye pressure and prevent vision loss, not to relieve inflammation or discomfort.
Choice C reason: Using the eye drops until a smaller angle can be restored is not an accurate response, as it confuses open-angle glaucoma with closed-angle glaucoma. Open-angle glaucoma is characterized by a wide and open angle between the iris and the cornea, which allows the aqueous humor to flow freely. Closed-angle glaucoma is characterized by a narrow or closed angle that blocks the drainage of the aqueous humor. The eye drops are used to lower the eye pressure and prevent further damage to the optic nerve, not to change the angle of the eye.
Choice D reason: Using the eye drops for long-term control of normal eye pressure is the most accurate response, as it reflects the purpose and duration of the treatment. Open-angle glaucoma is a chronic condition that requires lifelong management. The eye drops are used to lower the eye pressure and prevent vision loss, which can occur if the pressure is too high for too long. The client should use the eye drops as prescribed and follow up with the healthcare provider regularly.
Correct Answer is B
Explanation
Choice A reason: Keeping an oral liquid or glucose source available is a good intervention for any client who is receiving insulin, as it can help treat hypoglycemia, which is a low blood sugar level. However, it is not the most important intervention for a client who is receiving insulin lispro, which is a rapid-acting insulin that starts working within 15 minutes and lasts for 2 to 4 hours. The nurse should ensure that the client has a meal ready before giving this insulin, as it can cause severe hypoglycemia if the client does not eat soon after.
Choice B reason: Providing meals at the same time this insulin is given is the most important intervention for a client who is receiving insulin lispro, which is a rapid-acting insulin that mimics the natural insulin response to a meal. The nurse should coordinate the timing of the insulin injection and the meal, as the insulin will lower the blood sugar level quickly and the meal will provide the glucose needed to prevent hypoglycemia. The nurse should also teach the client and the family about the importance of eating within 15 minutes of taking this insulin.
Choice C reason: Assessing for hypoglycemia between meals is a good intervention for any client who is receiving insulin, as it can help detect and treat low blood sugar levels. However, it is not the most important intervention for a client who is receiving insulin lispro, which is a rapid-acting insulin that has a short duration of action. The risk of hypoglycemia is highest during the peak of the insulin action, which is 30 to 90 minutes after the injection. The nurse should monitor the client's blood sugar level more frequently during this time and provide snacks as needed.
Choice D reason: Checking blood glucose levels every six hours is not a sufficient intervention for a client who is receiving insulin lispro, which is a rapid-acting insulin that requires more frequent monitoring. The nurse should check the blood glucose level before each meal and at bedtime, as well as before and after exercise, to adjust the insulin dose and prevent hyperglycemia or hypoglycemia. The nurse should also teach the client and the family how to use a glucometer and record the blood glucose results.
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