A patient with liver failure has been admitted with hepatic encephalopathy and is prescribed lactulose every 2 hours. The patient is currently oriented and has had 6 loose, watery stools since 0700.
The 1400 dose of lactulose is due.
What should be the nurse’s next course of action?
No action is required as this is the desired therapeutic effect.
Withhold the dose and contact the doctor for daily stool count parameters.
Administer the medication since diarrhea is a common side effect.
Remove fall precautions due to changes in mental status.
The Correct Answer is A
Choice A rationale
Lactulose is used to treat hepatic encephalopathy, a condition that affects patients with liver failure. It works by reducing the absorption of ammonia in the gut. Having loose, watery stools is a desired therapeutic effect of lactulose. Therefore, no action is required if the patient is oriented and has had 6 loose, watery stools since 07007.
Choice B rationale
Withholding the dose and contacting the doctor for daily stool count parameters is not necessary in this situation. The patient is currently oriented, which suggests that the lactulose is effectively managing their hepatic encephalopathy.
Choice C rationale
Administering the medication because diarrhea is a common side effect is not the correct course of action. The presence of loose, watery stools is not merely a side effect, but a desired therapeutic effect of lactulose in the treatment of hepatic encephalopathy.
Choice D rationale
Removing fall precautions due to changes in mental status is not necessary in this situation. The patient is currently oriented, which suggests that the lactulose is effectively managing their hepatic encephalopathy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Metformin is an oral antidiabetic medication that is typically withheld on the morning of surgery due to the risk of lactic acidosis, especially if the surgery involves the use of contrast dye.
Choice B rationale
Metoprolol is a beta-blocker used to treat hypertension and other heart conditions. It is typically continued up to and including the day of surgery to maintain heart rate and blood pressure control.
Choice C rationale
Prednisone is a corticosteroid medication. If a patient is on long-term corticosteroid therapy, it is typically continued on the day of surgery to prevent adrenal insufficiency.
Choice D rationale
Levothyroxine is a thyroid hormone replacement medication. It is typically continued on the day of surgery to maintain thyroid hormone levels.
Correct Answer is C
Explanation
Choice A rationale
Monitoring blood pressure for hypertension during the infusion is important, but it is not the primary measure to reduce complications with vancomycin administration3.
Choice B rationale
Restricting fluids during vancomycin therapy is not recommended. Adequate hydration is important when receiving vancomycin to prevent kidney damage3.
Choice C rationale
Infusing the drug over at least 1 hour is the most crucial measure to reduce complications that may occur with vancomycin administration. This is to prevent “red man syndrome,” a reaction that can cause flushing, rash, and hypotension3.
Choice D rationale
Discontinuing the drug immediately if red man syndrome occurs is not the primary measure. The infusion can often be slowed down or temporarily stopped to manage this reaction3.
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