Lactulose was prescribed two days ago for a client who was recently diagnosed with hepatic encephalopathy. The client is confused and experiencing frequent loose stools. Laboratory findings show an elevated serum ammonia (NH) level of 220 μg/dL (157.1 μmol/dL). Which action should the nurse take?

Reference Range:

Ammonia [10 to 80 μg/dL (6 to 47 μmol/L)]

Hold the next dose of lactulose.

Continue the prescribed dose of lactulose.

Replace total volume voided with oral or IV fluids.

Report the number of diarrhea stools to the healthcare provider (HCP).

Answer and Explanation

The Correct Answer is B

B. Lactulose works by acidifying the colonic contents, which promotes the conversion of ammonia (NH3) to ammonium (NH4+). Ammonium is less readily absorbed from the colon into the bloodstream, reducing systemic ammonia levels. This action helps alleviate the neurotoxic effects of ammonia on the brain, thereby improving neurological symptoms associated with hepatic encephalopathy.
A. Lactulose is required in clients with hepatic encephalopathy to excrete ammonia lowering its levels in blood. Holding the lactulose dose is inappropriate as the client’s ammonia levels are still high
C. Rehydrating the clients to replace lost fluids in the loose stools is important but does not address
the client’s elevated ammonia levels which may be exacerbating the client’s encephalopathy.
D. Reporting the number of diarrhea stools to the healthcare provider is important for ongoing assessment and management of the client's condition. However, it does not address the clients high ammonia levels.

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Free Nursing Study Resources

Correct Answer is C

Explanation

C. Breakthrough pain is a transient exacerbation of pain that occurs despite the use of around- the-clock analgesics for persistent pain. Breakthrough pain episodes require rapid intervention with additional analgesics or adjustments to the current pain management regimen to provide adequate pain relief and improve the client's quality of life.
A. Replacing transdermal analgesic patches every 72 hours is important for ensuring consistent delivery of medication, but it is not directly related to addressing breakthrough pain.
B. Administering analgesics on a fixed and continuous schedule is important for maintaining baseline pain control, but it may not address breakthrough pain adequately.
D. Frequently evaluating the client's pain is essential, but monitoring specifically for breakthrough pain ensures timely intervention when pain exacerbations occur.

A. Administer a topical analgesic per protocol. B. Cleanse the tongue and mouth with swabs. C. Obtain a soft diet for the client. D. Encourage frequent mouth care.

Correct Answer is D

Explanation

D. Frequent mouth care helps maintain oral hygiene, reduces the risk of infection, and provides comfort to the client by removing debris and soothing irritated tissues.
A. Administering a topical analgesic may provide pain relief, but it should be done in accordance with the healthcare facility's protocol and after assessing the client's oral mucosa for any contraindications or precautions.
B. Cleaning the tongue and mouth with swabs can cause further irritation to the already sore oral tissues.
C. Obtaining a soft diet for the client is appropriate for minimizing trauma to the oral mucosa, but it may not address the immediate discomfort experienced by the client.

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Naxlex Comprehensive Predictor Exams

A client with metastatic cancer reports a pain level of 10 on a scale of 0 to 10. Twenty minutes after the nurse administers an IV analgesic, the client reports no pain relief. Which intervention is most important for the nurse to include in this client's plan of care?

Correct Answer is C

Explanation

The nurse is caring for a client with chemotherapy induced mucositis who is describing soreness of the tongue and oral tissues. Which is the best initial nursing action?

Correct Answer is D

Explanation

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