Nokea
The nurse is caring for a client with hepatic encephalopathy who is receiving lactulose. Which of the following findings would indicate that the medication has been effective?
- A. Improved mental status
- B. Looser consistency of stool
- C. Reduced abdominal distension
- D. Increased serum potassium level
Correct Answer: A
Rationale: Lactulose is used in hepatic encephalopathy to reduce ammonia levels by promoting its excretion through the stool. Improved mental status (A) indicates reduced ammonia toxicity, directly reflecting the medication's therapeutic effect. Looser stools (B) and reduced abdominal distension (C) are expected effects of lactulose but are secondary to the primary goal of ammonia reduction. Increased serum potassium (D) is incorrect, as lactulose does not directly affect potassium levels.
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The nurse is preparing to administer the fourth dose of vancomycin IVPB to a client with infective endocarditis. Which intervention should the nurse anticipate?
- A. Starting a new IV line before the administration
- B. Administering an antiemetic PRN prior to the infusion
- C. Administering medication via an infusion pump over at least 30 minutes
- D. Obtaining a serum trough level 15-30 minutes before the administration of vancomycin
Correct Answer: D
Rationale: Vancomycin requires therapeutic drug monitoring to ensure efficacy and prevent toxicity. Obtaining a serum trough level 15-30 minutes before the fourth dose (D) is standard to guide dosing adjustments. A new IV line (A) is unnecessary unless the current line is compromised. Antiemetics (B) are not routinely needed. Infusion over 60 minutes (C) is typical to prevent red man syndrome, not 30 minutes.
In assessing a post partum client, the nurse palpates a firm fundus and observes a constant trickle of bright red blood from the vagina. What is the most likely cause of these findings?
- A. Uterine atony
- B. Genital lacerations
- C. Retained placenta
- D. Clotting disorder
Correct Answer: B
Rationale: Genital lacerations. Continuous bleeding in the absence of a boggy fundus indicates undetected genital tract lacerations.
The nurse is reviewing a depressed client's history from an earlier admission. Documentation of anhedonia is noted. The nurse understands that this finding refers to
- A. Reports of difficulty falling and staying asleep
- B. Expression of persistent suicidal thoughts
- C. Lack of enjoyment in usual pleasures
- D. Reduced senses of taste and smell
Correct Answer: C
Rationale: Lack of enjoyment in usual pleasures. Anhedonia, a common finding in depression, is the lack of enjoyment in usual pleasures.
The nurse is discussing dementia with the families of older adults. All of the following behaviors are reported. Which behavior is most suggestive of dementia?
- A. The woman can't remember the birth year of each of her six children.
- B. A woman walked to the store and got lost on the way home.
- C. A woman forgot where she put her purse.
- D. A man is wearing one green sock and one red sock and doesn't see the difference.
Correct Answer: B
Rationale: Getting lost in a familiar area indicates significant spatial disorientation, a hallmark of dementia. Forgetting details, misplacing items, or color oversight are less specific.
At 26 weeks gestation, a client is admitted to the ER stating that she has been having a painless bloody vaginal discharge since last evening. The nurse should give priority to:
- A. Reporting the findings to the physician
- B. Evaluating the color of the discharge
- C. Evaluating the client's vital signs
- D. Applying an external fetal monitor
Correct Answer: A
Rationale: Painless bleeding at 26 weeks suggests placenta previa or abruption, requiring immediate physician notification . Assessing discharge , vitals , or fetal monitoring follows reporting.