Which of the following indicate to the nurse that lactulose is effective for an older adult who has advanced liver cirrhosis?
The client has at least one stool per day.
The client denies nausea and vomiting (N/V).
The client's bilirubin level decreases.
The client is alert and oriented (A&Ox4).
The Correct Answer is D
Choice A reason: While having at least one stool per day is a sign that lactulose is working, it does not directly indicate its effectiveness in reducing ammonia levels and improving mental status.
Choice B reason: Denial of nausea and vomiting is positive but is not a direct indicator of lactulose's effectiveness in treating hepatic encephalopathy.
Choice C reason: A decrease in bilirubin levels may be a positive sign, but it is not a direct indicator of lactulose's effectiveness in treating hepatic encephalopathy.
Choice D reason: The client being alert and oriented is a direct indicator that lactulose is effectively reducing ammonia levels and improving mental status, which is a key goal in treating hepatic encephalopathy associated with liver cirrhosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Systolic Blood Pressure is not a direct measure of preload; it indicates the pressure in the arteries during the contraction of the heart muscles.
Choice B reason: Mean Arterial Blood Pressure is an average blood pressure in an individual during a single cardiac cycle, but it does not specifically measure preload.
Choice C reason: Central Venous Pressure (CVP) is a direct measure of the blood volume returning to the heart and the ability of the heart to pump the blood into the arterial system, making it a key indicator of preload.
Choice D reason: Systemic Vascular Resistance refers to the resistance to blood flow offered by all of the systemic vasculature, excluding the pulmonary vasculature, and is not a measure of preload.
Correct Answer is C
Explanation
Choice A reason: While it is important to address any questions the patient may have, it is not the highest priority before an IVP procedure.
Choice B reason: Asking the patient to void before the procedure is a standard practice, but it is not the highest priority. The bladder should be empty to allow for clear imaging, but this can be managed at the time of the procedure.
Choice C reason: Checking for an allergy to iodine or shellfish is the highest priority because the contrast medium used in an IVP can cause severe allergic reactions in patients with these allergies. This assessment must be done before administering the contrast to prevent potentially life-threatening complications.
Choice D reason: Assessing the client's ability to remain still is important for the quality of the images, but it is not as critical as ensuring the safety of the patient regarding potential allergic reactions.
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