A client with hepatic encephalopathy is receiving lactulose. Which assessment provides the nurse with the best information to evaluate the client's therapeutic response to the drug?

Stool color and character.

Serum electrolytes and ammonia.

Serum hepatic enzymes.

Fingerstick glucose.

Answer and Explanation

The Correct Answer is B

Choice A reason: This is not the best assessment for the nurse to use to evaluate the client's therapeutic response to lactulose. Stool color and character may change as a result of lactulose administration, as it is a laxative that lowers the pH of the colon and promotes the excretion of ammonia. However, these changes are not indicative of the effectiveness of lactulose in reducing the ammonia levels in the blood, which is the main goal of the therapy.

Choice B reason: This is the best assessment for the nurse to use to evaluate the client's therapeutic response to lactulose. Serum electrolytes and ammonia are directly affected by lactulose administration, as it lowers the blood ammonia levels by converting it to ammonium and facilitating its elimination in the stool. The nurse should monitor the serum electrolytes and ammonia levels regularly to assess the efficacy and safety of lactulose therapy, as well as to adjust the dosage as needed.

Choice C reason: This is not the best assessment for the nurse to use to evaluate the client's therapeutic response to lactulose. Serum hepatic enzymes are markers of liver function and damage, and they may be elevated in clients with hepatic encephalopathy due to cirrhosis or other liver disorders. However, lactulose does not affect the hepatic enzymes directly, and it does not reverse the underlying liver disease. The nurse should monitor the serum hepatic enzymes to assess the progression and severity of the liver condition, but not to evaluate the response to lactulose.

Choice D reason: This is not the best assessment for the nurse to use to evaluate the client's therapeutic response to lactulose. Fingerstick glucose is a measure of blood glucose levels, and it may be altered in clients with hepatic encephalopathy due to impaired glucose metabolism by the liver. However, lactulose does not affect the blood glucose levels directly, and it does not improve the liver's ability to regulate glucose. The nurse should monitor the fingerstick glucose to assess the risk of hypoglycemia or hyperglycemia, but not to evaluate the response to lactulose.

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Correct Answer is B

Explanation

Choice A reason: Keeping an oral liquid or glucose source available is a good intervention for any client who is receiving insulin, as it can help treat hypoglycemia, which is a low blood sugar level. However, it is not the most important intervention for a client who is receiving insulin lispro, which is a rapid-acting insulin that starts working within 15 minutes and lasts for 2 to 4 hours. The nurse should ensure that the client has a meal ready before giving this insulin, as it can cause severe hypoglycemia if the client does not eat soon after.

Choice B reason: Providing meals at the same time this insulin is given is the most important intervention for a client who is receiving insulin lispro, which is a rapid-acting insulin that mimics the natural insulin response to a meal. The nurse should coordinate the timing of the insulin injection and the meal, as the insulin will lower the blood sugar level quickly and the meal will provide the glucose needed to prevent hypoglycemia. The nurse should also teach the client and the family about the importance of eating within 15 minutes of taking this insulin.

Choice C reason: Assessing for hypoglycemia between meals is a good intervention for any client who is receiving insulin, as it can help detect and treat low blood sugar levels. However, it is not the most important intervention for a client who is receiving insulin lispro, which is a rapid-acting insulin that has a short duration of action. The risk of hypoglycemia is highest during the peak of the insulin action, which is 30 to 90 minutes after the injection. The nurse should monitor the client's blood sugar level more frequently during this time and provide snacks as needed.

Choice D reason: Checking blood glucose levels every six hours is not a sufficient intervention for a client who is receiving insulin lispro, which is a rapid-acting insulin that requires more frequent monitoring. The nurse should check the blood glucose level before each meal and at bedtime, as well as before and after exercise, to adjust the insulin dose and prevent hyperglycemia or hypoglycemia. The nurse should also teach the client and the family how to use a glucometer and record the blood glucose results.

A. Stop the oral contraceptive immediately. B. Avoid prolonged exposure to direct sunlight. C. Take the medications at least 12 hours apart. D. Use an additional form of contraception.

Correct Answer is D

Explanation

Choice A reason: This is not a correct instruction for the nurse to provide to the client. Stopping the oral contraceptive immediately is not necessary, as it may cause irregular bleeding, hormonal imbalance, or unwanted pregnancy. The client should continue taking the oral contraceptive as prescribed, but use an additional form of contraception, such as condoms or spermicides, while taking erythromycin.

Choice B reason: This is not a correct instruction for the nurse to provide to the client. Avoiding prolonged exposure to direct sunlight is not related to the interaction between oral contraceptive and erythromycin. This instruction may be relevant for other antibiotics, such as tetracyclines or sulfonamides, that can cause photosensitivity and increase the risk of sunburn. The client should protect the skin from sun exposure as part of general health promotion, but it is not specific to erythromycin therapy.

Choice C reason: This is not a correct instruction for the nurse to provide to the client. Taking the medications at least 12 hours apart is not sufficient to prevent the interaction between oral contraceptive and erythromycin. Erythromycin is a macrolide antibiotic that can reduce the effectiveness of oral contraceptive by increasing its metabolism and clearance. The client should take the medications as prescribed, but use an additional form of contraception, such as condoms or spermicides, while taking erythromycin.

Choice D reason: This is the correct instruction for the nurse to provide to the client. Using an additional form of contraception is the best way to prevent pregnancy while taking erythromycin and oral contraceptive. Erythromycin can decrease the efficacy of oral contraceptive by increasing its metabolism and clearance. The client should use a barrier method or a spermicide, in addition to the oral contraceptive, while taking erythromycin and for at least one week after finishing the antibiotic course.

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A client with hepatic encephalopathy is receiving lactulose. Which assessment provides the nurse with the best information to evaluate the client's therapeutic response to the drug?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which intervention is most important for the nurse to implement for a client who is receiving insulin lispro?

Correct Answer is B

Explanation

A client who is taking an oral contraceptive receives a new prescription for erythromycin. Which instruction should the nurse provide to the client?

Correct Answer is D

Explanation

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