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 client is admitted to the medical unit with acute pancreatitis. While planning care for this client, the nurse will include which of the following interventions? (Select all that apply).
- A. Administer antiemetics as needed.
- B. Administer analgesics as needed.
- C. NPO (nothing by mouth) until pain-free.
- D. Monitor blood glucose and provide insulin as needed.
- E. Side-lying or fetal position.
- F. Monitor hydration status.
Correct Answer: A,B,C,D,F
Rationale: These interventions address pain management, pancreatic rest, glucose control, and hydration in acute pancreatitis.
A client with advanced cirrhosis has been admitted to the medical-surgical unit. The nurse is assessing the client and identifies which of the following findings as indicators of hepatic encephalopathy? (Select all that apply).
- A. Asterixis
- B. Change in orientation
- C. Anorexia
- D. Ascites
- E. Fetor hepaticus
Correct Answer: A,B,E
Rationale: These are signs of hepatic encephalopathy reflecting cerebral effects of ammonia toxicity.
A nurse is caring for a client who had a stroke and has dysphagia. For which of the following complications should the nurse monitor the client?
- A. Aspiration
- B. Gastroesophageal reflux disease
- C. Peptic ulcer disease
- D. Dumping syndrome
Correct Answer: A
Rationale: Aspiration is the primary concern with dysphagia due to impaired swallowing reflexes.
A nurse is caring for a client who has acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply).
- A. Hypoxemia
- B. Confusion
- C. Dyspnea
- D. Bradycardia
- E. Hypocarbia
Correct Answer: A,B,C,E
Rationale: These are common manifestations of ARF reflecting impaired gas exchange and cerebral effects of abnormal blood gases.
A nurse is teaching a group of nurses about the administration of nitroglycerin. Which of the following routes of administration provides the most rapid onset for the client?
- A. Topical ointment
- B. Sustained-release
- C. Sublingual
- D. Transdermal patch
Correct Answer: C
Rationale: Sublingual nitroglycerin has the fastest onset (1-3 minutes) due to direct absorption into bloodstream.