The nurse is caring for client with liver failure admitted with hepatic encephalopathy, Lactulose is ordered Q2 hours. What assessment finding should the nurse use to best evaluate therapeutic response of the medication?
The ammonia level has decreased each day starting the lactulose
The liver enzymes AST and ALT. have decreased to normal levels
The client is having 5-6 soft, non-formed stools each day
The client is awake, alert and oriented to their environment
The Correct Answer is D
A) The ammonia level has decreased each day starting the lactulose: While a decrease in ammonia levels is an important indicator of improvement in hepatic encephalopathy, it is not the best assessment of the therapeutic response to lactulose. The goal of lactulose therapy is to reduce ammonia levels, but the most direct evaluation of therapeutic effect is related to the client's mental status, not just laboratory results.
B) The liver enzymes AST and ALT have decreased to normal levels: Liver enzyme levels such as AST (aspartate aminotransferase) and ALT (alanine aminotransferase) are important indicators of liver function, but they do not directly reflect the effectiveness of lactulose in treating hepatic encephalopathy. These enzymes may improve as liver function improves, but they are not the most immediate or specific indicator of lactulose’s therapeutic effect.
C) The client is having 5-6 soft, non-formed stools each day: Lactulose works by drawing water into the bowel to promote stool softening and increase bowel movements, which can help lower ammonia levels in the body. While frequent soft stools can be an effect of lactulose, this is not the best measure of therapeutic response in hepatic encephalopathy. The primary goal is improvement in the client's mental status, not just bowel function.
D) The client is awake, alert, and oriented to their environment: The best assessment of the therapeutic response to lactulose is the improvement in the client’s mental status. Lactulose works by reducing the absorption of ammonia from the gastrointestinal tract, which is responsible for the cognitive impairments seen in hepatic encephalopathy. If the client is awake, alert, and oriented, this indicates that lactulose is effectively reducing the ammonia levels and improving the neurological status of the client, making it the most appropriate assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Problems that cause severe discomfort to the client: While addressing discomfort is important in providing holistic care, it is not the highest priority in nursing. The nurse’s primary focus should be on life-threatening issues or those that could deteriorate the client’s condition rapidly. Severe discomfort can be managed once immediate threats to life are addressed.
B) Problems the client deems most important: Although it’s essential to consider the client’s perspective and involve them in their care plan, problems that are most important to the client may not always be the most urgent or life-threatening. For example, the client may prioritize pain management, but addressing life-threatening issues must always take precedence.
C) Problems that are immediately life-threatening for the client: This is the correct answer. According to Maslow’s hierarchy of needs and the nursing prioritization framework, life-threatening problems should always be the nurse's first priority. These are issues that, if not addressed immediately, can lead to death or severe complications. For instance, airway obstruction, severe bleeding, or shock would require immediate intervention.
D) Problems that are identified as priority by the physician: While the physician’s orders and priorities should be taken into consideration, the nurse must independently assess and prioritize care based on the overall health status of the client. This includes using clinical judgment to identify life-threatening conditions, even if they are not explicitly stated in the physician’s orders. Nurses are trained to identify priority issues through their assessments and are responsible for making decisions that ensure the client’s safety.
Correct Answer is ["12"]
Explanation
1. Convert the child's weight from pounds to kilograms:
There are approximately 2.2 pounds in 1 kilogram.
33 pounds / 2.2 pounds/kg = 15 kg (approximately)
2. Calculate the total milligrams of amoxicillin needed per dose:
The order is for 20 mg/kg/dose.
The child weighs 15 kg.
20 mg/kg * 15 kg = 300 mg
3. Determine the concentration of the amoxicillin suspension:
The label shows the concentration is 125 mg/5 mL.
4. Set up a proportion to find the volume (in mL) needed:
125 mg / 5 mL = 300 mg / x mL
5. Solve for x:
Cross-multiply: 125x = 300 * 5
125x = 1500
x = 1500 / 125
x = 12 mL
Answer: You will administer 12 mL per dose.
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