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 B
Explanation
Choice A reason (precautions): Droplet precautions are not the primary recommendation for Hepatitis A, as it is not primarily spread through droplets.
Choice B reason (precautions): Contact precautions are recommended for patients with Hepatitis A due to the risk of fecal-oral transmission, especially in a patient with incontinence.
Choice C reason (precautions): While standard precautions are always necessary, they are not sufficient alone for Hepatitis A, which requires additional precautions due to its mode of transmission.
Choice D reason (precautions): Airborne precautions are not required for Hepatitis A, as it is not spread through the air.
Correct Answer is C
Explanation
Choice A reason: Taking several deep breaths is not specifically related to the preparation for a renal system physical assessment. Deep breaths are more commonly associated with lung examination or to help the patient relax.
Choice B reason: Drinking several glasses of water before a renal assessment could potentially fill the bladder, which might interfere with palpation of the kidneys and make it uncomfortable for the patient.
Choice C reason: Emptying the bladder is the correct action before a renal system physical assessment. It allows for better palpation of the kidneys and other structures without the discomfort of a full bladder. It also prevents the possibility of the patient urinating involuntarily during the examination due to a full bladder.
Choice D reason: Providing a urine sample might be part of the overall renal assessment, but it is not necessary to do so immediately before the physical examination of the renal system. The sample can be collected at any time before or after the physical examination.
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