HESI RN Exit Exam 2024 Quizlet Related

Review HESI RN Exit Exam 2024 Quizlet related questions and content

After receiving lactulose, a client with hepatic encephalopathy has several loose stools. What action should the nurse implement?

  • A. Send stool specimen to the lab
  • B. Measure abdominal girth
  • C. Encourage increased fiber in the diet
  • D. Monitor mental status
Correct Answer: D

Rationale: The correct action for the nurse to implement after a client with hepatic encephalopathy has loose stools following lactulose administration is to monitor the client's mental status. Lactulose is given to lower serum ammonia levels in hepatic encephalopathy, and loose stools can be an expected side effect of its use. Monitoring mental status is crucial because changes in mental status, such as confusion or altered level of consciousness, are key indicators of hepatic encephalopathy worsening. Sending a stool specimen to the lab would not be the priority in this situation as loose stools are a known effect of lactulose. Measuring abdominal girth is more relevant for conditions like ascites, not loose stools. Encouraging increased fiber in the diet may be beneficial for constipation but is not the immediate action needed when loose stools occur after lactulose administration.