The healthcare provider prescribes lactulose for a patient with hepatic encephalopathy. What will the nurse assess to determine the effectiveness of this medication?

Decreased ammonia levels

Relief of constipation

Decreased liver enzymes

Relief of abdominal pain

Answer and Explanation

The Correct Answer is A

Choice A reason:Lactulose is used in hepatic encephalopathy primarily to lower blood ammonia levels. It works by converting ammonia in the intestines into ammonium, which is then excreted³. Therefore, a decrease in ammonia levels would indicate the effectiveness of the medication.

Choice B reason:While lactulose can relieve constipation due to its laxative effect, relief of constipation is not the primary indicator of its effectiveness in treating hepatic encephalopathy³.

Choice C reason:Decreased liver enzymes are not a direct measure of lactulose's effectiveness in hepatic encephalopathy. Liver enzymes are indicators of liver function, not ammonia levels³.

Choice D reason:Relief of abdominal pain is not a specific indicator of lactulose's effectiveness in hepatic encephalopathy. The medication's primary role is to reduce ammonia levels, not to alleviate pain³.

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Correct Answer is B

Explanation

Choice A reason: Asterixis, also known as “liver flap,” is a type of tremor characterized by rapid, nonrhythmic extensions and flexions in the wrist and fingers. It is associated with hepatic encephalopathy, a condition that can occur with severe liver disease, but it is not a direct indicator of low albumin levels.

Choice B reason: Peripheral edema is a common clinical finding in patients with hypoalbuminemia, which is a low level of albumin in the blood. When albumin levels are low, fluid from the bloodstream can leak into body tissues, causing swelling, especially in the lower limbs. When assessing a client with liver disease and low albumin levels, palpating for peripheral edema would be the most relevant nursing assessment, as it directly correlates with the effects of hypoalbuminemia on fluid balance in the body. Albumin is a protein made by the liver that helps keep fluid in your blood vessels and plays a role in transporting substances throughout your body. Low levels of albumin can lead to fluid leaking out of blood vessels into tissues, causing swelling or edema.

Choice C reason: Decreased level of consciousness can be a sign of various conditions, including hepatic encephalopathy or other complications of liver disease, but it is not specifically indicative of low albumin levels.

Choice D reason: Petechiae are small red or purple spots caused by bleeding into the skin and may be associated with various conditions, including liver disease, but they are not a specific sign of low albumin levels.

A. Label the feeding bag with the date and time of the start of the feeding. B. Aspirate the client's stomach contents. C. Hang the feeding bag 30 cm (12 inches) above the client. D. Warm the feeding to room temperature.

Correct Answer is B

Explanation

Choice A reason:Labeling the feeding bag with the date and time is important for tracking, but it is not the first action to take. The priority is to ensure that the NG tube is correctly placed and the stomach contents can be aspirated to verify placement before administering the feeding.

Choice B reason:Aspirating the client's stomach contents is the first action the nurse should take. This is to confirm the correct placement of the NG tube to prevent complications such as aspiration pneumonia. It is a critical step before starting any enteral feeding.

Choice C reason: Hanging the feeding bag 30 cm (12 inches) above the client is necessary for gravity feeding, but it comes after verifying the NG tube placement through aspiration of stomach contents.

Choice D reason:Warming the feeding to room temperature is a comfort measure and helps to prevent gastrointestinal discomfort. However, it is not the first action to take. The priority is to check the tube placement.

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The healthcare provider prescribes lactulose for a patient with hepatic encephalopathy. What will the nurse assess to determine the effectiveness of this medication?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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