Nokea
A client with a history of liver failure is prescribed lactulose (Cephulac). The nurse should monitor the client for which of the following therapeutic effects?
- A. Decreased ammonia levels.
- B. Increased blood glucose.
- C. Decreased blood pressure.
- D. Increased platelet count.
Correct Answer: A
Rationale: Lactulose reduces ammonia levels by promoting its excretion in hepatic encephalopathy.
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A client with a history of tuberculosis is prescribed isoniazid (INH). The nurse should monitor the client for which of the following adverse effects?
- A. Hepatotoxicity.
- B. Hypoglycemia.
- C. Hypertension.
- D. Weight loss.
Correct Answer: A
Rationale: Isoniazid can cause hepatotoxicity, requiring regular liver function monitoring.
Which of the following is NOT an essential minimal component of the teaching that occurs prior to getting an informed consent?
- A. The purpose of the proposed treatment or procedure
- B. The expected outcomes of the proposed treatment or procedure
- C. Who will perform the treatment or procedure
- D. When the procedure or treatment will be done
Correct Answer: D
Rationale: Essential components of informed consent include the purpose , expected outcomes , and who will perform the procedure . The specific timing is not a required minimal component.
After surgery to create a urinary diversion, the client is at risk for a urinary tract infection. The nurse should plan to incorporate which of the following interventions into the client's care?
- A. Clamp the urinary appliance at night.
- B. Empty the urinary appliance when one-third full.
- C. Administer prophylactic antibiotics.
- D. Change the urinary appliance daily.
Correct Answer: B
Rationale: Emptying the appliance when one-third full prevents urine stasis, reducing infection risk.
A client is prescribed morphine sulfate for postoperative pain. Which side effect should the nurse monitor for?
- A. Hypertension
- B. Tachycardia
- C. Respiratory depression
- D. Diarrhea
Correct Answer: C
Rationale: Morphine, an opioid, can cause respiratory depression, a serious side effect requiring close monitoring to ensure client safety.
The client is having ototoxic effects of the vestibular branch of the acoustic nerve. The nurse should assess the client for which of the following? Select all that apply.
- A. Vertigo.
- B. Tinnitus.
- C. Nausea.
- D. Ataxia.
- E. Hearing loss.
Correct Answer: A,C,D
Rationale: Ototoxicity affecting the vestibular branch causes vertigo, nausea, and ataxia due to balance disruption. Tinnitus and hearing loss are associated with cochlear branch damage.