Nokea
When lactulose (Cephulac) 30 ml QID is prescribed for a male client with advanced cirrhosis, and he complains that it causes diarrhea, what action should the nurse take in response to the client's statement?
- A. Explain that diarrhea is expected, but the drug reduces ammonia levels
- B. Document that the client is non-compliant with his treatment plan
- C. Tell the client to be concerned about more significant side effects of this drug
- D. Obtain a prescription for loperamide (Imodium) 4mg PO PRN diarrhea
Correct Answer: A
Rationale: The correct answer is A. Diarrhea is an expected side effect of lactulose when used to reduce ammonia levels in cirrhosis. It helps in decreasing the absorption of ammonia in the colon, thereby reducing its levels in the blood. Option B is incorrect because it is essential for the nurse to educate the client about the expected side effects of the medication rather than assuming non-compliance. Option C is incorrect as it instills unnecessary fear in the client by suggesting more significant side effects without addressing the current concern. Option D is incorrect as loperamide should not be given automatically for diarrhea caused by lactulose, as the diarrhea is a therapeutic effect of the medication in this context.
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A client with diabetic peripheral neuropathy has been taking pregabalin for 4 days. Which finding indicates to the nurse that the medication is effective?
- A. Granulating tissue in foot ulcer
- B. Full volume of pedal pulse
- C. Reduced level of pain
- D. Improved visual activity
Correct Answer: C
Rationale: The correct answer is C: 'Reduced level of pain.' Pregabalin is used to manage neuropathic pain, so a reduction in pain indicates the medication's effectiveness in this case. Granulating tissue in a foot ulcer and the full volume of a pedal pulse are not direct indicators of pregabalin's effectiveness in managing neuropathic pain. Improved visual activity is not related to the effects of pregabalin in diabetic peripheral neuropathy.
A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first?
- A. Review the heart rhythm on cardiac monitors
- B. Check urinary catheter for obstruction
- C. Auscultate bilateral breath sounds
- D. Give PRN dose of lorazepam (Ativan)
Correct Answer: B
Rationale: When a client in the intensive care unit is mechanically ventilated, has an indwelling urinary catheter, and is restless, the priority action is to check the urinary catheter for obstruction. Restlessness in this context could be due to a blocked catheter causing discomfort or urinary retention, which needs immediate attention to prevent complications. Reviewing the heart rhythm on cardiac monitors can be important but is not the priority in this scenario. Auscultating bilateral breath sounds is also important in a ventilated client but addressing the potential immediate issue of a blocked catheter takes precedence. Giving a PRN dose of lorazepam should not be the first action without addressing the underlying cause of restlessness.
After receiving a report on an inpatient acute care unit, which client should the nurse assess first?
- A. The client with bowel obstruction due to a volvulus who is experiencing abdominal rigidity
- B. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds
- C. The client with an obstruction of the large intestine who is experiencing abdominal distention
- D. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid
Correct Answer: A
Rationale: The correct answer is A. Abdominal rigidity in a client with bowel obstruction due to a volvulus indicates possible complications and requires immediate assessment. Choice B is incorrect because although a paralytic ileus with absent bowel sounds is concerning, abdominal rigidity in a client with a volvulus takes priority. Choice C is incorrect as abdominal distention, though indicative of an obstruction, is not as urgent as the sign of abdominal rigidity. Choice D is incorrect as the drainage of greenish fluid from a nasogastric tube in a client with a small bowel obstruction, while concerning, does not present as immediate a threat as the abdominal rigidity in a client with a volvulus.
A client who is scheduled to have surgery in two hours tells the nurse, 'My doctor was here and used a lot of big words about the surgery, then asked me to sign a paper.' What action should the nurse take?
- A. Reassure the client that pre-surgery anxiety is a normal experience
- B. Explain the surgery in clear terms that the client can understand
- C. Call the surgeon back to clarify the information with the client
- D. Redirect the client's thoughts by teaching relaxation techniques
Correct Answer: B
Rationale: The correct action for the nurse to take in this situation is to explain the surgery to the client in clear terms that they can understand. This will help alleviate the client's anxiety and ensure they are well-informed about the procedure they are about to undergo. Choice A is incorrect because while reassurance is important, it does not address the client's specific concern about understanding the surgery. Choice C is not the initial step; the nurse should first attempt to clarify the information themselves. Choice D is not the priority when the client is seeking clarification about the surgery.
When entering a client's room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which actions should the nurse implement?
- A. Ignore the behavior and administer the IV antibiotic
- B. Tell the client to stop the inappropriate behavior
- C. Leave the room and close the door quietly
- D. Complete an unusual occurrence report
Correct Answer: C
Rationale: The correct action for the nurse in this situation is to leave the room and close the door quietly. This response respects the client's privacy, maintains professionalism, and avoids interrupting the client's personal moment. Choice A is incorrect because ignoring the behavior is not appropriate and may invade the client's privacy further. Choice B is incorrect as it can embarrass the client and the visitor, breaching their privacy and dignity. Choice D is also incorrect as the immediate priority is to respect the client's privacy and address the situation discreetly.