A client presents to the emergency department with muscle aches, headache, fever, and describes a recent loss of taste and smell.
The nurse obtains a nasal swab for COVID-19 testing. Which action is most important for the nurse to take?

Choice A rationale:

Lactulose directly addresses the primary cause of hepatic encephalopathy, which is the accumulation of ammonia in the blood. Ammonia is a neurotoxin that can impair brain function, leading to confusion, lethargy, and even coma. Lactulose works by trapping ammonia in the colon, where it can be safely excreted in the stool. This decrease in ammonia levels in the blood allows for the improvement of mental status.

Studies have consistently shown that lactulose therapy can significantly improve mental function in patients with hepatic encephalopathy. This improvement is often seen within a few days of starting treatment.

The nurse should assess the client's mental status regularly to monitor for improvement. This assessment should include evaluating the client's level of consciousness, orientation, attention, memory, and speech.

Improved mental status is a critical therapeutic goal in the treatment of hepatic encephalopathy. It allows patients to regain their independence and participate more fully in their care.

Choice B rationale:

While lactulose can cause diarrhea, which may lead to a slight increase in urine output, this is not the primary therapeutic response that the nurse should expect.

The increase in urine output is typically secondary to the diarrhea and does not directly reflect a reduction in ammonia levels or improvement in mental status.

Choice C rationale:

Lactulose does cause diarrhea, which is a common side effect of the medication.

However, the goal of lactulose therapy is not to reduce the number of liquid stools but rather to trap ammonia in the colon and promote its excretion.

The nurse should monitor the client's stool frequency and consistency to ensure that they are not experiencing excessive diarrhea, which could lead to dehydration and electrolyte imbalances.

Choice D rationale:

While improved mental status may eventually lead to improved mobility, it is not the most immediate or direct therapeutic response that the nurse should expect from lactulose therapy.

The ability to ambulate independently is more likely to be a long-term goal of treatment, rather than an immediate response to lactulose.

Choice A rationale:

Deep breathing and coughing exercises are not a priority intervention immediately following eye surgery. They are more commonly used to prevent postoperative pulmonary complications, such as pneumonia or atelectasis, in patients who have undergone general anesthesia or have respiratory conditions.

While deep breathing and coughing exercises can help promote circulation and prevent blood clots, they are not directly relevant to protecting the eye after surgery.

Engaging in deep breathing and coughing exercises too soon after eye surgery could potentially increase intraocular pressure, which could strain the healing eye and potentially lead to complications.

Choice B rationale:

Obtaining vital signs every 2 hours is a standard nursing intervention for monitoring a patient's overall condition, but it is not the most immediate priority following eye surgery.

Vital signs can provide important information about the patient's heart rate, blood pressure, respiratory rate, and temperature, but they do not directly address the protection of the surgically treated eye.

While monitoring vital signs is important, it does not specifically address the prevention of injury or complications to the eye itself.

Choice C rationale:

Providing an eye shield is the most crucial intervention to protect the eye immediately following surgery. The eye shield serves several important purposes:

Protection from accidental injury: It prevents the patient from accidentally rubbing or bumping the eye during sleep, which could cause further damage or disrupt the healing process.

Prevention of infection: It helps to keep the eye clean and free from debris, reducing the risk of infection. Reduction of swelling: It can help to minimize swelling and discomfort by applying gentle pressure to the eye area.

Promotion of healing: By creating a dark and protected environment, the eye shield can promote rest and healing of the tissues.

Choice D rationale:

Teaching a family member to administer eye drops is an important intervention for long-term care, but it is not the most immediate priority following surgery.

The patient may be able to administer eye drops independently, or a nurse may be responsible for administering them in the initial post-operative period.

Focusing on teaching family members about eye drop administration right after surgery could distract from more urgent priorities, such as protecting the eye with an eye shield.