Nokea
A client with cirrhosis is taking lactulose (Cephulac). Which finding indicates that the lactulose is having the desired effect?
- A. Two to three soft bowel movements per day
- B. Increased serum ammonia levels
- C. Decreased white blood cell count
- D. Soft, formed stool twice a day
Correct Answer: A
Rationale: The correct answer is A: 'Two to three soft bowel movements per day.' Lactulose is prescribed to produce soft, regular bowel movements to reduce ammonia levels in clients with cirrhosis. This helps in preventing hepatic encephalopathy. Option B is incorrect because increased serum ammonia levels would indicate that lactulose is not effectively reducing ammonia levels. Option C is incorrect because lactulose does not directly affect white blood cell counts. Option D is incorrect because soft, formed stools twice a day may not be frequent enough to effectively reduce ammonia levels in clients with cirrhosis.
You may also like to solve these questions
The nurse is assessing on the first postoperative day following thyroid surgery. Which laboratory value is most important for the nurse to monitor?
- A. Calcium
- B. Sodium
- C. Chloride
- D. Potassium
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse in a community health clinic is interviewing a female client who has three children. The client tells the nurse that she has a new man in her life, with whom she is having a sexual relationship, and that they both smoke cigarettes. Which information is most important for the nurse to provide this client?
- A. Oral contraceptives should be started to prevent an unwanted pregnancy
- B. Children are more prone to upper respiratory infections if exposed to smoke at home
- C. Cigarette smoking increases the risk for peptic ulcers and emphysema
- D. A diaphragm and condom provide effective contraception when used together
Correct Answer: D
Rationale: The most important information for the nurse to provide the client in this situation is that using both a diaphragm and a condom together provides effective contraception and also protects against sexually transmitted diseases (STDs). While oral contraceptives can help prevent unwanted pregnancies, using a barrier method like a diaphragm and a condom is crucial in this scenario where the client is engaging in a new sexual relationship. Choice B is important information but is not the top priority in this context. Choice C, although relevant, does not address the immediate concern of contraception and STD prevention. Therefore, the correct answer is D.
At a community health fair, a 50-year-old woman tells the nurse that she has an annual physical exam that includes a clinical breast exam and an annual mammogram. How should the nurse respond?
- A. Encourage the woman to explore her fears about breast cancer.
- B. Ask the woman if she also performs monthly breast self-exams.
- C. Commend the woman for adhering to the recommended cancer detection guidelines.
- D. Advise the woman that mammograms are only needed every two years at her age.
Correct Answer: B
Rationale: The correct answer is B. Monthly breast self-exams are essential for early detection of breast cancer. While annual clinical breast exams and mammograms are important, monthly self-exams enhance early detection by helping women become familiar with their breasts and notice any changes. Choice A is incorrect as it does not address the importance of self-exams. Choice C is incorrect as it prematurely commends without ensuring the woman is conducting self-exams. Choice D is incorrect as it provides inaccurate information about the frequency of mammograms needed.
A client in acute renal failure has a serum potassium of 7.5 mEq/L. Based on this finding, the nurse should anticipate implementing which action?
- A. Administer an IV of normal saline rapidly and NPH insulin subcutaneously.
- B. Administer a retention enema of Kayexalate.
- C. Add 40 mEq of KCL (potassium chloride) to the present IV solution.
- D. Administer a lidocaine bolus IV push.
Correct Answer: B
Rationale: In acute renal failure with a high serum potassium level, the priority intervention is to lower potassium levels to prevent complications like cardiac arrhythmias. Administering a retention enema of Kayexalate is the correct action as it helps lower high potassium levels by exchanging sodium for potassium in the intestines. Options A, C, and D are incorrect. Administering normal saline rapidly and NPH insulin or adding more potassium to the IV solution can further increase potassium levels, worsening the condition. Lidocaine is not indicated for treating hyperkalemia.
When preparing an educational program for adolescents about the risks of multiple sexual partners, which information is most important to include?
- A. Condoms provide reliable protection against sexually transmitted infections.
- B. Having multiple sexual partners increases the risk of contracting sexually transmitted infections.
- C. The use of oral contraceptives can reduce the risk of sexually transmitted infections.
- D. Having multiple sexual partners increases the risk of developing cancer.
Correct Answer: B
Rationale: The correct answer is B because having multiple sexual partners significantly increases the risk of contracting sexually transmitted infections (STIs). This information is crucial for adolescents to understand the potential consequences of engaging in risky sexual behaviors. Choice A is incorrect because while condoms are important for protection, they are not 100% effective. Choice C is incorrect as oral contraceptives do not protect against STIs. Choice D is incorrect as the immediate concern for adolescents in this context is the risk of STIs rather than cancer.