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The nurse is caring for a client with hepatic encephalopathy who is receiving lactulose. Which of the following findings would indicate that the medication has been effective?
- A. Improved mental status
- B. Looser consistency of stool
- C. Reduced abdominal distension
- D. Increased serum potassium level
Correct Answer: A
Rationale: Lactulose is used in hepatic encephalopathy to reduce ammonia levels by promoting its excretion through the stool. Improved mental status (A) indicates reduced ammonia toxicity, directly reflecting the medication's therapeutic effect. Looser stools (B) and reduced abdominal distension (C) are expected effects of lactulose but are secondary to the primary goal of ammonia reduction. Increased serum potassium (D) is incorrect, as lactulose does not directly affect potassium levels.
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A nurse is caring for a client 2 days after surgical creation of an arteriovenous fistula in the forearm. Which finding should the nurse report immediately to the health care provider?
- A. 2+ pitting edema of the extremity with the arteriovenous fistula
- B. Loud swooshing sound auscultated over the arteriovenous fistula
- C. Pale skin of the hand of the arm with the arteriovenous fistula
- D. Surgical site pain reported by the client as 3 on a scale of 0-10 during hand exercises
Correct Answer: C
Rationale: Pale skin in the hand (C) suggests vascular compromise, risking fistula failure or ischemia, requiring immediate reporting. Edema (A) is common, a swooshing sound (B) indicates patency, and mild pain (D) is expected.
The nurse observes a client using a walker. Which observation indicates that the client needs more instruction?
- A. The client uses the walker to pull herself out of a chair.
- B. The client moves the walker forward and then takes a step.
- C. The client complains that the walker is not waist high.
- D. The client sometimes does not use the walker.
Correct Answer: A
Rationale: Using the walker to pull up risks tipping, indicating improper use and a need for further instruction on safe walker technique.
Which response by the nurse would best assist the chemically impaired client to deal with issues of guilt?
- A. Addiction usually causes people to feel guilty. Don't worry, it is a typical response due to your drinking behavior.
- B. What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?
- C. Don't focus on your guilty feelings. These feelings will only lead you to drinking and taking drugs.
- D. You've caused a great deal of pain to your family and close friends, so it will take time to undo all the things you've done.
Correct Answer: B
Rationale: This response encourages the client to get in touch with their feelings and utilize problem-solving steps to reduce guilt feelings.
The nurse is to change a dressing. Which is essential to do when opening the dressing set?
- A. Open the first flap away from the nurse.
- B. Open the first flap toward the nurse.
- C. Place the dressing set on a chair beside the bed.
- D. Place the dressing set on the client's bed.
Correct Answer: A
Rationale: The first flap should be opened away from the nurse to allow the last flap to be opened toward the nurse, preventing contamination. The dressing set should be placed at waist height on a clean surface like an overbed table, not on the bed or a chair.
The nurse is caring for a client with hyperparathyroidism who had a parathyroidectomy 4 hours ago. Which technique should the nurse use to check for complications in this client?
- A. Ask the client to place the backs of the hands against each other to provide hyperextension of the wrist while the elbows remain flexed
- B. Perform the Romberg test by asking the client to stand with the eyes closed and the feet together
- C. Place a blood pressure (BP) cuff on the client's arm, inflate to pressure greater than systolic BP, and monitor for carpal spasm
Correct Answer: C
Rationale: Post-parathyroidectomy, hypocalcemia is a potential complication due to reduced parathyroid hormone levels. Trousseau’s sign (C), elicited by inflating a BP cuff to induce carpal spasm, indicates hypocalcemia, a critical complication requiring prompt intervention. The wrist hyperextension test (A) is unrelated to hypocalcemia, and the Romberg test (B) assesses balance, not relevant to this scenario.