Which of the following indicate to the nurse that lactulose is effective for an older adult who has advanced liver cirrhosis?
The client has at least one stool per day.
The client denies nausea and vomiting (N/V).
The client's bilirubin level decreases.
The client is alert and oriented (A&Ox4).
The Correct Answer is D
Choice A reason: While having at least one stool per day is a sign that lactulose is working, it does not directly indicate its effectiveness in reducing ammonia levels and improving mental status.
Choice B reason: Denial of nausea and vomiting is positive but is not a direct indicator of lactulose's effectiveness in treating hepatic encephalopathy.
Choice C reason: A decrease in bilirubin levels may be a positive sign, but it is not a direct indicator of lactulose's effectiveness in treating hepatic encephalopathy.
Choice D reason: The client being alert and oriented is a direct indicator that lactulose is effectively reducing ammonia levels and improving mental status, which is a key goal in treating hepatic encephalopathy associated with liver cirrhosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Muscle dysfunction can be a consequence of COPD due to decreased activity levels, but it is not a risk factor for developing COPD.
Choice B reason: Poor nutrition can affect the overall health of individuals with COPD but is not a direct risk factor for developing the disease.
Choice C reason: Weight loss can occur in advanced stages of COPD due to increased energy expenditure from breathing difficulties, but it is not a risk factor for developing COPD.
Choice D reason: Increased risk for pneumonia is a direct risk associated with COPD, as the disease can compromise the respiratory system's ability to clear infections.
Correct Answer is A
Explanation
Choice A reason (client care): A client reporting shortness of breath may be experiencing a life-threatening situation that aligns with the ABCs (Airway, Breathing, Circulation) of patient prioritization. This client requires immediate assessment and intervention.
Choice B reason (client care): While discharge is important, it does not take precedence over a client with potential respiratory distress.
Choice C reason (client care): A client who received pain medication 30 minutes ago is likely stable and can be seen after more urgent cases are addressed.
Choice D reason (client care): A client waiting for an abdominal x-ray is not a priority over a client with respiratory issues.
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