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The client is admitted with end-stage liver failure and is prescribed the laxative lactulose (Chronulac). Which statement indicates the client needs more teaching concerning this medication?
- A. I should have two to three soft stools a day.
- B. I must check my ammonia level daily.
- C. If I have diarrhea, I will call my doctor.
- D. I should check my stool for any blood.
Correct Answer: B
Rationale: Clients do not routinely check ammonia levels at home; this is done clinically if needed. The other statements reflect correct understanding of lactulose use for hepatic encephalopathy.
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The client is diagnosed with an acute exacerbation of IBD. Which priority intervention should the nurse implement?
- A. Weigh the client daily and document in the client's chart.
- B. Teach coping strategies such as dietary modifications.
- C. Record the frequency, amount, and color of stools.
- D. Monitor the client's oral fluid intake every shift.
Correct Answer: C
Rationale: Recording stool frequency, amount, and color is critical in acute IBD exacerbation to assess disease activity and guide treatment. Weight and fluid monitoring are important but secondary, and teaching is less urgent during an acute phase.
The client is admitted to a medical unit. The client’s medication list includes rifaximin, lactulose, and propranolol. Which assessment should be the nurse’s priority based on the client’s medication list?
- A. Assess the client for a history of PUD.
- B. Assess the client for abdominal pain.
- C. Place the client on airborne precautions.
- D. Assess neurological status and abdominal girth.
Correct Answer: D
Rationale: A. Antibiotics and acid-reducing medications are expected with the treatment of PUD, but propranolol (Inderal) would not be expected. Although these medications may cue the nurse to further explore a history of PUD, this is not the most likely conclusion. B. There is no indication that the client has abdominal pain, and there isn’t an analgesic on the medication list. C. There is no indication that the client has an infectious condition necessitating airborne precautions. D. All medications listed are used to treat liver cirrhosis and its complications of portal hypertension and hepatic encephalopathy. The antibiotic rifaximin (Xifaxan) and the laxative lactulose (Cephulac) are used for treating hepatic encephalopathy. Thus, assessing the client’s neurological status and measuring abdominal girth are most important.
The nurse is caring for clients on a surgical unit. Which client should the nurse assess first?
- A. The client who had an inguinal hernia repair and has not voided in four (4) hours.
- B. The client who was admitted with abdominal pain who suddenly has no pain.
- C. The client four (4) hours postoperative abdominal surgery with no bowel sounds.
- D. The client who is one (1) day postappendectomy and is being discharged.
Correct Answer: B
Rationale: Sudden resolution of abdominal pain may indicate perforation (e.g., appendicitis), a life-threatening emergency requiring immediate assessment. Urinary retention, absent bowel sounds, and discharge are less urgent.
The 20-year-old female is being admitted to the hospital with exacerbation of Crohn’s disease. The client is alert and oriented and has been taking azathioprine for disease control. Into which room should the charge nurse place the client?
- A. Private room across from the nurse’s station
- B. Room with a female who has Crohn’s disease
- C. Private room that has a private attached bathroom
- D. Room with an elderly female who is on bedrest
Correct Answer: C
Rationale: A. The client is alert and oriented; there is no need to be near the nurse’s station. B. The client is at an increased risk for infection and should have a private room rather than rooming with another female with Crohn’s disease. C. The client should be in a private room with a private bathroom due to an increased risk for infection with azathioprine (Imuran). Azathioprine suppresses cell-mediated immune responses and may cause bone marrow suppression. It is also a biohazard medication. D. The client is at an increased risk for infection and should have a private room rather than rooming with another female.
Following an esophagectomy with colon interposition (esophagoenterostomy) for esophageal cancer, the client is beginning to eat oral foods. The nurse monitors for aspiration because the client no longer has which structure?
- A. A stomach
- B. A pyloric sphincter
- C. A pharynx
- D. A lower esophageal sphincter
Correct Answer: D
Rationale: A. All or part of the stomach will remain intact following an esophagoenterostomy. B. The pyloric sphincter will remain intact following an esophagoenterostomy. C. The pharynx will remain intact following an esophagoenterostomy. D. An esophagectomy for cancer involves removal of the lower esophageal sphincter, which normally functions to keep food from refluxing back into the esophagus. The absence of the lower esophageal sphincter places the client at risk for aspiration.