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 A
Explanation
Choice A reason: This is the correct action for the nurse to take. Risedronate is a bisphosphonate that is used to treat osteoporosis by inhibiting bone resorption. It should be taken with a full glass of water at least 30 minutes before the first food or drink of the day, as food and beverages can reduce its absorption and effectiveness. Milk and other dairy products are especially problematic, as they contain calcium, which can bind to risedronate and prevent it from reaching the bone.
Choice B reason: This is not a correct action for the nurse to take. Assigning a UAP to bring the client a glass of low fat milk is not appropriate, as it contradicts the instruction to take risedronate with water only. Low fat milk still contains calcium, which can interfere with risedronate absorption. The nurse should educate the client and the UAP about the proper administration of risedronate and the importance of avoiding food and beverages for at least 30 minutes after taking the medication.
Choice C reason: This is not a correct action for the nurse to take. Consulting with a pharmacist about scheduling the dose one hour after the client eats is not necessary, as risedronate should be taken before the first food or drink of the day, not after. Taking risedronate one hour after eating may not ensure adequate absorption and efficacy, as food and beverages can remain in the stomach for longer periods of time. The nurse should follow the prescribed schedule and the manufacturer's guidelines for risedronate administration.
Choice D reason: This is not a correct action for the nurse to take. Withholding the medication until the client's breakfast tray is available on the unit is not advisable, as it may delay the treatment of osteoporosis and increase the risk of fractures. Risedronate should be taken as soon as possible after waking up, before the first food or drink of the day, to maximize its absorption and effectiveness. The nurse should not postpone the medication administration without consulting the healthcare provider.
Correct Answer is B
Explanation
Choice A reason: Performing a neurological exam is not the priority action in this situation. Confusion and blurred vision are signs of hypoglycemia, which is a low blood sugar level. Glipizide is a medication that lowers blood sugar by stimulating the pancreas to produce more insulin. The nurse should first confirm the blood sugar level before performing any other assessments or interventions.
Choice B reason: Obtaining a fingerstick blood glucose is the best action in this situation. This is a quick and easy way to measure the blood sugar level and determine if the client is experiencing hypoglycemia. The nurse should use a glucometer and a lancet to prick the client's finger and obtain a drop of blood. The nurse should compare the result with the normal range and follow the hypoglycemia protocol.
Choice C reason: Administering glucagon intramuscularly is not the first action in this situation. Glucagon is a hormone that raises blood sugar by stimulating the breakdown of glycogen in the liver. It is used as an emergency treatment for severe hypoglycemia, when the client is unconscious or unable to swallow. The nurse should only administer glucagon after confirming the blood sugar level and trying oral glucose first.
Choice D reason: Measuring the client's vital signs is not the priority action in this situation. Vital signs include blood pressure, pulse, respiration, and temperature. They can provide information about the client's overall health and stability, but they are not specific to hypoglycemia. The nurse should focus on the blood sugar level, which is the most relevant indicator of hypoglycemia.
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