A client with cirrhosis of the liver is having numerous, liquid, incontinent stools, and continues to be confused. In reviewing the client's laboratory studies, the nurse identifies an elevated serum ammonia level. Based on this finding, which prescription is most important for this client to receive?

Loperamide.

Furosemide.

Lactulose.

Intravenous (IV) human albumin.

Answer and Explanation

The Correct Answer is C

A. Loperamide: Although it treats diarrhea, loperamide would worsen ammonia buildup by reducing bowel transit time. It doesn’t address the underlying hepatic encephalopathy causing confusion in cirrhosis.

B. Furosemide: This loop diuretic is used to manage ascites or edema, not elevated ammonia. It doesn’t treat the neurological symptoms caused by hepatic encephalopathy or improve stool-based ammonia excretion.

C. Lactulose: Lactulose lowers serum ammonia by trapping it in the colon and promoting its excretion through diarrhea. It directly treats confusion related to hepatic encephalopathy, making it the most important intervention here.

D. Intravenous (IV) human albumin: Albumin helps restore oncotic pressure in cases of ascites or low serum protein but does not affect ammonia levels or mental status. It supports fluid balance, not toxin elimination.

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Correct Answer is A

Explanation

A. Palpate the client's suprapubic area for distention: The symptoms suggest possible urinary retention, which could be a result of benign prostatic hyperplasia (BPH) or another obstruction. Palpating the suprapubic area for distention is important to assess for urinary retention and determine if the bladder is full.

B. Obtain a urine specimen for culture and sensitivity: Although a urinary tract infection can cause urinary symptoms, the client's presentation is more likely indicative of a physical obstruction such as BPH. A culture might be needed later if infection is suspected.

C. Instruct in effective techniques to cleanse the glans penis: Proper hygiene is important, especially in older adult men, but this is not the most relevant action for the symptoms described. The focus should be on assessing for possible urinary retention or obstruction.

D. Advise the client to maintain a voiding diary for one week: While a voiding diary may provide useful information for monitoring symptoms over time, the immediate priority is to assess for urinary retention and bladder distention.

A. Supine positioning. B. Verbal reassurance. C. Physical soothing. D. Simultaneous injections.

Correct Answer is D

Explanation

A. Supine positioning: While positioning may help comfort the child, it does not directly reduce the pain associated with vaccinations. The focus should be on strategies that address pain management during the procedure.

B. Verbal reassurance: Verbal reassurance is helpful for reducing anxiety, but it may not be enough to reduce the pain during the injection. The toddler may not fully understand verbal comfort in a way that would minimize discomfort.

C. Physical soothing: Physical soothing, such as holding or rocking the child, may help calm the toddler, but it does not directly reduce the pain associated with receiving multiple injections. It can, however, provide emotional comfort.

D. Simultaneous injections: Administering multiple injections at once (if prescribed and safe to do so) can reduce the overall duration of pain, as it minimizes the number of needle sticks. This approach allows for the vaccines to be given quickly, reducing the time the child is experiencing discomfort.

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Naxlex Comprehensive Predictor Exams

An older adult male client arrives at the clinic reporting that his bladder always feels full. The client also reports a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating the urine stream. Which action should the nurse implement?

Correct Answer is A

Explanation

The nurse is administering multiple prescribed vaccines to a toddler. Which strategy should the nurse prioritize to reduce the duration of pain?

Correct Answer is D

Explanation

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