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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is not a correct information for the nurse to include in the discharge instructions. Taking the tablet with a daily multivitamin is not advisable, as some vitamins and minerals, such as calcium, zinc, and vitamin C, can interfere with the absorption of iron and reduce its effectiveness. The client should take the tablet on an empty stomach or with a small amount of food that does not contain these substances.
Choice B reason: This is not a correct information for the nurse to include in the discharge instructions. Bedtime is not the best time to take the tablet, as it may cause gastrointestinal side effects, such as nausea, vomiting, constipation, or diarrhea, that can disrupt the client's sleep and comfort. The client should take the tablet at least 2 hours before or after meals, and preferably in the morning.
Choice C reason: This is a correct information for the nurse to include in the discharge instructions. Waiting 2 hours after meals to take the tablet is recommended, as it ensures that the stomach is empty and that the iron is not affected by any food or beverages that may impair its absorption. The client should also drink plenty of water with the tablet to facilitate its passage and prevent irritation of the esophagus.
Choice D reason: This is not a correct information for the nurse to include in the discharge instructions. Crushing the tablets and mixing with pudding is not appropriate, as it can damage the enteric coating of the tablets, which is designed to protect the iron from being destroyed by the stomach acid and to reduce the gastrointestinal side effects. The client should swallow the tablets whole and not chew, break, or crush them.
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.
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