The patient’s vital signs are as follows: Temperature 97.5 F (36.4 C), Heart rate 104 beats/minute, Respirations 29 breaths/minute, Blood pressure 119/82 mm Hg, Oxygen saturation 89%. Oxygen mask applied.
What should the nurse do next?

Choice A rationale:

Lactulose directly addresses the primary cause of hepatic encephalopathy, which is the accumulation of ammonia in the blood. Ammonia is a neurotoxin that can impair brain function, leading to confusion, lethargy, and even coma. Lactulose works by trapping ammonia in the colon, where it can be safely excreted in the stool. This decrease in ammonia levels in the blood allows for the improvement of mental status.

Studies have consistently shown that lactulose therapy can significantly improve mental function in patients with hepatic encephalopathy. This improvement is often seen within a few days of starting treatment.

The nurse should assess the client's mental status regularly to monitor for improvement. This assessment should include evaluating the client's level of consciousness, orientation, attention, memory, and speech.

Improved mental status is a critical therapeutic goal in the treatment of hepatic encephalopathy. It allows patients to regain their independence and participate more fully in their care.

Choice B rationale:

While lactulose can cause diarrhea, which may lead to a slight increase in urine output, this is not the primary therapeutic response that the nurse should expect.

The increase in urine output is typically secondary to the diarrhea and does not directly reflect a reduction in ammonia levels or improvement in mental status.

Choice C rationale:

Lactulose does cause diarrhea, which is a common side effect of the medication.

However, the goal of lactulose therapy is not to reduce the number of liquid stools but rather to trap ammonia in the colon and promote its excretion.

The nurse should monitor the client's stool frequency and consistency to ensure that they are not experiencing excessive diarrhea, which could lead to dehydration and electrolyte imbalances.

Choice D rationale:

While improved mental status may eventually lead to improved mobility, it is not the most immediate or direct therapeutic response that the nurse should expect from lactulose therapy.

The ability to ambulate independently is more likely to be a long-term goal of treatment, rather than an immediate response to lactulose.

The correct answer is choice A, C, and D.

Choice A rationale:

The patient’s oxygen saturation is at 94%, which is just below the normal range of 95-100% for healthy adults breathing room air. Administering oxygen 2 to 4 liters to maintain oxygen saturation at or above 95% is a standard intervention to ensure adequate oxygenation.

Choice B rationale:

A stat ventilation/perfusion (V/Q) scan is typically ordered for suspected pulmonary embolism, which is not indicated by the patient’s current data. The patient’s symptoms do not specifically suggest a V/Q mismatch that would necessitate this diagnostic test.

Choice C rationale:

A chest x-ray is a common diagnostic tool for evaluating the lungs and heart, especially when a patient presents with symptoms that may indicate respiratory or cardiac issues. Given the patient’s temperature and heart rate, which are slightly elevated, a chest x-ray can help identify any potential underlying conditions.

Choice D rationale:

Ordering a CBC, BMP, and blood cultures can help identify the cause of the patient’s fever and tachycardia. These tests provide valuable information about the patient’s immune response, electrolyte balance, kidney function, and whether there is a bacterial infection.

Choice E rationale:

While sending sputum for culture and sensitivity could be helpful if a respiratory infection is suspected, the patient’s data does not strongly indicate a respiratory infection as the primary issue. Therefore, this test may not be the most immediate need.