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).

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason : While maintaining a stable ECG rhythm is important, it is not the highest priority. The primary concern is to address life-threatening complications.

Choice B reason : Educating the patient about the causes and eﬀects of coronary heart disease (CHD) or coronary artery disease (CAD) is important for long-term management but is not the immediate priority during acute care.

Choice C reason : Adequate relief of pain is the highest priority in the care of a patient with AMI. Pain is an indicator of ongoing ischemia and can increase the workload of the heart, thereby worsening the condition.

Choice D reason (AMI): While bedrest is part of the care plan, it is not the highest priority compared to pain relief, which has direct implications on the patient's immediate physiological status.

A. Evaluating the eﬀectiveness of opioid analgesics B. Limiting the patient's intake of oral and IV ﬂuids C. Teaching the patient about high-protein, high-calorie foods D. Encouraging the patient to ambulate as much as tolerated

Correct Answer is A

Explanation

Choice A reason: Evaluating the eﬀectiveness of opioid analgesics is crucial as pain management is a primary concern for patients experiencing a sickle cell crisis.

Choice B reason: Limiting the patient's intake of oral and IV ﬂuids is not recommended as hydration is important for patients with sickle cell crisis to reduce blood viscosity and improve circulation.

Choice C reason: Teaching the patient about high-protein, high-calorie foods is beneficial for long-term management but is not the immediate nursing intervention during a crisis.

Choice D reason: Encouraging ambulation may be part of recovery but is not the primary intervention during an acute sickle cell crisis due to the risk of pain exacerbation.

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Which of the following indicate to the nurse that lactulose is eﬀective for an older adult who has advanced liver cirrhosis?

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Naxlex Comprehensive Predictor Exams

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