after receiving lactulose a client with hepatic encephalopathy has several loose stools what action should the nurse implement
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HESI RN

HESI RN Exit Exam 2024 Quizlet

1. After receiving lactulose, a client with hepatic encephalopathy has several loose stools. What action should the nurse implement?

Correct answer: D

Rationale: The correct action for the nurse to implement after a client with hepatic encephalopathy has loose stools following lactulose administration is to monitor the client's mental status. Lactulose is given to lower serum ammonia levels in hepatic encephalopathy, and loose stools can be an expected side effect of its use. Monitoring mental status is crucial because changes in mental status, such as confusion or altered level of consciousness, are key indicators of hepatic encephalopathy worsening. Sending a stool specimen to the lab would not be the priority in this situation as loose stools are a known effect of lactulose. Measuring abdominal girth is more relevant for conditions like ascites, not loose stools. Encouraging increased fiber in the diet may be beneficial for constipation but is not the immediate action needed when loose stools occur after lactulose administration.

2. The nurse enters a client's room and observes the unlicensed assistive personnel (UAP) making an occupied bed. What action should the nurse take first?

Correct answer: A

Rationale: The correct answer is to place the side rails in an up position first. This action is essential to prevent the client from falling while the bed is being made. Assisting the UAP in turning the client (Choice B) is not the immediate priority. Providing instructions on bed-making techniques (Choice C) can wait until the safety of the client is ensured. Asking the client if they are comfortable (Choice D) is important but should come after ensuring the client's safety by raising the side rails.

3. A 75-year-old female client is admitted to the orthopedic unit following an open reduction and internal fixation of a hip fracture. On the second postoperative day, the client becomes confused and repeatedly asks the nurse where she is. What information is most important for the nurse to obtain?

Correct answer: A

Rationale: The correct answer is A: History of alcohol use. In this scenario, obtaining the history of alcohol use is crucial as it could indicate withdrawal, which might explain the client's confusion. Alcohol withdrawal can lead to symptoms such as confusion, agitation, and disorientation. While knowing the current medication list (choice B) is important for overall patient care, in this case, alcohol withdrawal is a more likely cause of the confusion. Baseline cognitive status (choice C) is valuable for comparison but may not directly explain the sudden confusion. Family history of dementia (choice D) is less relevant in this acute situation compared to the potential immediate impact of alcohol withdrawal.

4. While caring for a toddler receiving oxygen (02) via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement?

Correct answer: D

Rationale: A water-soluble lubricant is safe to use in conjunction with oxygen therapy, unlike petroleum jelly which is flammable.

5. The nurse weighs a 6-month-old infant during a well-baby check-up and determines that the baby's weight has tripled compared to the birth weight of 7 pounds 8 ounces. The mother asks if the baby is gaining enough weight. What response should the nurse offer?

Correct answer: A

Rationale: The correct answer is A: 'Your baby is gaining weight right on schedule.' Tripling of birth weight by 6 months is a normal growth pattern in infants, indicating appropriate weight gain and development. Choice B is unrelated to the question as it focuses on the baby's diet rather than addressing the weight gain concern. Choice C is incorrect as tripling the birth weight is considered a healthy growth pattern, not below normal percentile. Choice D is irrelevant to the mother's question about the adequacy of weight gain.

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