the client with cirrhosis of the liver is receiving lactulose the nurse is aware that the rationale for the order for lactulose is
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Nursing Elites

NCLEX-PN

Nclex Practice Questions 2024

1. The client with cirrhosis of the liver is receiving Lactulose. The nurse is aware that the rationale for the order for Lactulose is:

Correct answer: C

Rationale: Lactulose is administered to the client with cirrhosis to lower ammonia levels, as it works by acidifying the colon, trapping ammonia for elimination in the stool. Choices A, B, and D are incorrect because Lactulose does not have an effect on blood glucose, uric acid, or creatinine levels. Therefore, the correct answer is to lower the ammonia level.

2. Which information obtained from the mother of a child with cerebral palsy most likely correlates to the diagnosis?

Correct answer: B

Rationale: The diagnosis of meningitis at age 6 months correlates to a diagnosis of cerebral palsy. Cerebral palsy, a neurological disorder, is often associated with birth trauma or infections of the brain or spinal column. Answers A, C, and D are not related to the question. Gestational length (choice A) is not a direct risk factor for cerebral palsy. Physiologic jaundice (choice C) and frequent sore throats (choice D) are not typically associated with cerebral palsy.

3. An adolescent female reports being raped at a party where alcohol was served. The client admits to drinking alcohol before being raped by an acquaintance. The nurse should:

Correct answer: C

Rationale: In cases of rape, it is crucial to provide support and reassurance to the victim. The nurse should inform the client that it was not her fault and offer support through the physical examination. Blaming the victim, as in choice A, is inappropriate and can be damaging to the client's well-being. Choice B is not the priority at this moment; the immediate focus should be on supporting the client. Choice D is victim-blaming and implies doubt about the client's report, which is harmful and not supportive. It is essential to create a safe and supportive environment for the client to facilitate healing and recovery.

4. The nurse is caring for a client scheduled for a surgical repair of a sacular abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period?

Correct answer: C

Rationale: The most crucial assessment during the preoperative period for a client scheduled for surgical repair of a sacular abdominal aortic aneurysm is the identification of peripheral pulses. This is essential because during surgery, the aorta will be clamped, potentially affecting blood circulation to the kidneys and lower extremities. Monitoring peripheral pulses helps assess circulation to the lower extremities, ensuring adequate perfusion. While assessing the client's anxiety level (choice A) is important, it is not as critical as monitoring peripheral pulses in this case. Evaluating exercise tolerance (choice B) is not typically recommended preoperatively for this specific condition. Assessing bowel sounds and activity (choice D) is also relevant but takes a lower priority compared to identifying peripheral pulses in this scenario.

5. A client is given an opiate drug for pain relief following general anesthesia. The client becomes extremely somnolent with respiratory depression. The physician is likely to order the administration of:

Correct answer: A

Rationale: The correct answer is naloxone (Narcan). Naloxone is an opioid antagonist used to reverse opioid-induced respiratory depression and somnolence. In this scenario, the client's extreme somnolence and respiratory depression suggest an opioid overdose, making naloxone the appropriate choice to counteract these effects. Labetalol (Normodyne) is a nonselective beta-blocker used to treat hypertension, not opioid overdose. Neostigmine (Prostigmin) is a cholinesterase inhibitor used to reverse neuromuscular blockade, not opioid-induced respiratory depression. Thiothixene (Navane) is an antipsychotic medication used to treat schizophrenia and is not indicated for opioid overdose.

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