The nurse evaluates a client's response to lactulose treatment. Which finding indicates an expected outcome?

The client develops diarrhea.

The client has four to five soft bowel movements per day.

The client's speech becomes clear and appropriate.

The client develops fetor hepaticus and asterixis

Answer and Explanation

The Correct Answer is B

Rationale:

A. Lactulose can cause loose stools, but diarrhea is not the desired therapeutic outcome. Excessive diarrhea can lead to dehydration, electrolyte imbalances, and worsening confusion, which are adverse effects rather than expected responses.

B. Lactulose is used to reduce serum ammonia levels in clients with hepatic encephalopathy by promoting excretion of ammonia through the stool. The expected therapeutic outcome is regular, soft bowel movements, typically two to five per day, without causing excessive diarrhea. This indicates that ammonia is being cleared effectively, reducing neurotoxic effects.

C. Improvement in mental status is the ultimate goal of lactulose therapy, but it may take several doses to achieve. Immediate changes in speech are not expected and do not solely indicate treatment effectiveness.

D. Fetor hepaticus (a characteristic musty breath odor) and asterixis (flapping tremor of the hands) are signs of worsening hepatic encephalopathy. Their appearance would indicate treatment failure or progression of disease, not a positive response.

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Correct Answer is C

Explanation

Rationale:

A. Although emphasizing privacy is important, this statement does not directly address the client’s cultural or religious preference for a female examiner. Simply stating that all providers respect privacy may be perceived as dismissive, and it fails to reassure the client that their specific request will be honored. Cultural sensitivity requires recognizing and validating the client’s values, not just general privacy assurances.

B. This statement minimizes the client’s cultural and religious beliefs by suggesting that covering the client compensates for the presence of a male examiner. In many Muslim traditions, modesty and gender-specific care are critical. Ignoring these preferences can cause distress, reduce trust in healthcare providers, and potentially discourage the client from seeking care in the future.

C. This response acknowledges and respects the client’s religious and cultural values. It communicates that the healthcare team is willing to accommodate the client’s preference for a female examiner whenever possible, without guaranteeing it in situations where staffing limitations may exist. This approach promotes cultural competence, patient-centered care, and trust in the healthcare relationship, while balancing clinical needs and practical limitations.

D. This response is culturally insensitive, dismissive, and likely to create conflict or distress for the client and their family. It fails to recognize the importance of religious beliefs in patient care, which is essential in culturally competent nursing practice. Such a statement can damage the nurse-client relationship and reduce patient cooperation.

A. Check vital signs for signs of hypovolemic shock B. Assess for abdominal distension and pain C. Monitor for signs of infection at the biopsy site D. Evaluate the client's level of consciousness

Correct Answer is A

Explanation

Rationale:

A. The most serious and potentially life-threatening complication after a liver biopsy is hemorrhage. Bleeding may occur either at the puncture site or internally within the abdominal cavity. Early signs of hypovolemic shock include hypotension, tachycardia, tachypnea, and cool, clammy skin. Monitoring vital signs frequently—typically every 15 minutes for the first hour and then at progressively longer intervals if stable—allows the nurse to detect bleeding early and intervene promptly. Early recognition is essential because internal bleeding may not be immediately visible, and delays can result in rapid deterioration and death. Vital signs are therefore the priority assessment immediately post-procedure.

B. This is incorrect as the primary focus, though it remains an important secondary assessment. Abdominal pain, tenderness, or distension may indicate bleeding or bile leakage, but vital signs usually change before these physical findings become apparent. Relying solely on subjective symptoms could delay recognition of serious complications.

C. Infection is a potential late complication of liver biopsy, typically developing days after the procedure. While monitoring the site for redness, swelling, or drainage is part of ongoing post-procedure care, it is not the immediate priority compared to detecting life-threatening hemorrhage.

D. This is incorrect as the primary immediate assessment. Changes in mental status may indicate severe hypovolemia, hypoxia, or hepatic encephalopathy, but they are less sensitive and later indicators than vital sign changes. By the time significant mental status changes occur, the client may already be in advanced shock, making early vital sign monitoring more critical.

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The nurse evaluates a client's response to lactulose treatment. Which finding indicates an expected outcome?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse provides care to a Muslim client who presents to the emergency department with abdominal pain and vaginal bleeding. The client's spouse asks that only a female examines the client. Which is the most culturally appropriate statement by the nurse in response to the request?

Correct Answer is C

Explanation

After undergoing a liver biopsy, which post-procedure assessment is the nurse's priority?

Correct Answer is A

Explanation

The nurse admits a client with acute pancreatitis accompanied by biliary dysfunction. The nurse reviews the client's lab values. Which findings are anticipated? Select all that apply.

A client, diagnosed with acute pancreatitis 5 days ago, is experiencing respiratory distress. Which assessment finding is the greatest concern?

During morning rounds, the nurse notices that a client admitted 3 days ago with hepatic encephalopathy is sleepy and confused. The client is scheduled for discharge later today. Which interventions are appropriate for the nurse to implement? Select all that apply.

The nurse assesses a client with a pleural chest tube inserted to treat a pneumothorax. Which findings require immediate notification to the provider? Select all that apply.

The nurse notes new areas of ecchymosis on the arms and legs of a client with liver cirrhosis. Which laboratory test results should the nurse monitor because of this finding? Select all that apply.

A nurse is caring for a client who has cirrhosis of the liver. Which of the following assessment findings require immediate follow-up? Select all that apply.

A client is admitted to the emergency department with abdominal pain. Which data should the nurse document regarding a client's complaint of abdominal pain? Select all that apply.

The nurse is caring for the client following a liver biopsy with the assistance of the student nurse. Which action by the student nurse demonstrates an understanding of the post-procedural care?