Nokea
The healthcare provider prescribes lactulose for a patient with hepatic encephalopathy. What will the nurse assess to determine the effectiveness of this medication?
- A. Decreased ammonia levels
- B. Relief of constipation
- C. Decreased liver enzymes
- D. Relief of abdominal pain
Correct Answer: A
Rationale: Lactulose works by reducing blood ammonia levels, which is its primary mechanism in treating hepatic encephalopathy.
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A nurse is completing an assessment of a client who has a gastric ulcer. Which of the following findings should the nurse expect? (Select all that apply).
- A. The client states that pain occurs 30 minutes to 60 minutes after a meal.
- B. The client states that pain often occurs at night.
- C. The client reports a sensation of bloating.
- D. The client reports pain relieved by eating.
- E. The client experiences pain upon palpation of the epigastric region.
Correct Answer: A,B,C,D,E
Rationale: All options are common findings in gastric ulcer patients due to gastric acid secretion patterns and mucosal irritation.
The client is scheduled to receive 30 grams of lactulose orally every 12 hours. An oral solution containing 5 g/10 mL is available. How many mL should be poured into the medication cup to administer the required dose?
Correct Answer: 60
Rationale: Calculation: (30 g ÷ 5 g) × 10 mL = 60 mL
A nurse is caring for a client who has a chest tube in place connected to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?
- A. Occasional bubbling in the water-seal chamber
- B. No reports of pleuritic chest pain
- C. No tidaling in the water-seal chamber
- D. Oxygen saturation of 95%
Correct Answer: C
Rationale: Absence of tidaling indicates lung re-expansion as intrapleural pressure equalizes.
A nurse is caring for a client during his first hemodialysis treatment. The client reports a headache, nausea, and is agitated. Which of the following complications should the nurse identify these findings as manifestations of?
- A. Disequilibrium syndrome
- B. Septicemia
- C. Air embolism
- D. Peritonitis
Correct Answer: A
Rationale: These are classic symptoms of disequilibrium syndrome from rapid fluid/electrolyte shifts during initial dialysis.
A nurse in the emergency department is caring for a client who took three nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now is experiencing a headache. Which of the following statements should the nurse make?
- A. A headache is an indication of an allergy to the medication.
- B. A headache is an expected adverse effect of the medication.
- C. A headache is likely due to the anxiety about the chest pain.
- D. A headache indicates tolerance to the medication.
Correct Answer: B
Rationale: Headaches are a common side effect of nitroglycerin due to its vasodilating effects on cerebral arteries.