Patient Data
Mark whether the assessment finding represents a therapeutic result of the lactulose administered, a nontherapeutic side effect, or an unrelated finding. Each row must have one option selected.
Large, liquid stool
Abdomen soft and flat
Blood pressure 120/68 mm Hg
Drowsiness
Heart rate 62 beats/minute
Pain rating of 2 on a 0 to 10
Cramping
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"C"},"G":{"answers":"B"}}
Large, liquid stool: Lactulose is prescribed to treat constipation by drawing water into the bowel and promoting a bowel movement. A large, liquid stool indicates that the medication has effectively relieved the client's postoperative constipation.
Abdomen soft and flat: Before receiving lactulose, the client had a distended abdomen. A soft, flat abdomen afterward shows that bowel motility improved and gas or stool buildup has decreased, reflecting therapeutic action.
Blood pressure 120/68 mm Hg: Lactulose does not significantly affect blood pressure. A normal blood pressure reading is a positive finding but is unrelated to the expected outcomes or side effects of lactulose therapy.
Drowsiness: Drowsiness is not an intended or expected effect of lactulose. It may result from opioid use (morphine) rather than the lactulose itself, but since it impacts the client's alertness, it is considered a nontherapeutic side effect here.
Heart rate 62 beats/minute: Lactulose has no direct pharmacologic impact on heart rate. A heart rate of 62 beats per minute is within acceptable limits for many adults and is unrelated to the administration of lactulose.
Pain rating of 2 on a 0 to 10 scale: Pain control relates to the administration of morphine and other analgesics, not to lactulose. Therefore, a lower pain score reflects effective analgesia but is not linked to lactulose therapy.
Cramping: Cramping can occur with lactulose because it increases bowel motility and draws fluid into the intestines. Although mild cramping is expected, it is still classified as a nontherapeutic side effect because it can cause client discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Temperature of 100.8° F (38.2° C): A mildly elevated temperature in a post-transplant client may suggest infection or early rejection, both of which warrant monitoring. However, this is not a direct reason to withhold cyclosporine, which is essential for preventing organ rejection.
B. Elevated blood urea nitrogen (BUN): Elevated BUN could indicate impaired renal function, which should be monitored during cyclosporine therapy. However, this alone is not an urgent reason to withhold the medication without further evaluation of kidney function trends and symptoms.
C. Renal output of 120 mL/hour: This is a healthy urine output and suggests good renal perfusion and function. It does not present any contraindication to continuing cyclosporine and supports that the transplanted kidney is functioning well.
D. Blood pressure 180/98 mm Hg: Hypertension is a known side effect of cyclosporine and can become severe. A blood pressure this high, especially when accompanied by headache and blurred vision, suggests possible cyclosporine-induced hypertensive crisis or toxicity, and warrants immediate withholding of the medication and notification of the HCP.
Correct Answer is A
Explanation
A. Observe bowel movement pattern and take a stool softener: Morphine commonly causes constipation due to reduced gastrointestinal motility. Recognizing this and taking preventive measures like a stool softener indicates a good understanding of how to manage one of the most frequent and bothersome side effects of opioid therapy.
B. Do not drink grapefruit juice after taking morphine: Grapefruit juice significantly interacts with certain medications, particularly those metabolized by CYP3A4 enzymes, but it has minimal clinical effect on morphine metabolism. This instruction is not relevant for morphine use.
C. Watch for signs of agitation and record any insomnia: While these symptoms can occasionally occur, they are not typical or expected side effects of morphine. More common effects include sedation, respiratory depression, and constipation.
D. Take the benzodiazepine at the same time of taking the morphine: Combining morphine with benzodiazepines increases the risk of severe sedation, respiratory depression, and overdose. Co-administration should be carefully managed and typically avoided unless specifically directed by the healthcare provider.
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