Question

A client has been administered lactulose for several days. Which therapeutic response should the nurse expect for a client with hepatic encephalopathy?

Answer 1

Correct Answers:

Improved mental status.

Rationale :

🧪Lactulose works by reducing ammonia absorption in the intestines, which helps lower serum ammonia levels in clients with hepatic encephalopathy.

🧠By facilitating ammonia excretion through increased bowel movements, it improves neurological function and mental clarity.

💊Unlike diuretics or stimulants, lactulose has no effect on urine output or physical mobility, so improved ambulation is not its primary therapeutic goal.

📈The presence of more liquid stools is expected; however, the desired outcome is enhanced cognition, not stool consistency.

📌Core Message

Lactulose improves mental status in hepatic encephalopathy by lowering serum ammonia levels through its osmotic laxative effect.

Answer 2

Correct Answers:

Leave the old ties in place until the new ones are secure.

Rationale :

🔗When changing tracheostomy ties, maintaining airway security is the top priority to prevent accidental decannulation.

🩺Removing the old ties before securing the new ones can cause the tracheostomy tube to dislodge, especially in clients with copious secretions.

🧷While knot placement and types of collars may offer comfort or reduce irritation, they do not substitute for ensuring tube stability during tie replacement.

🚨This technique minimizes risk during care of a client with a surgical airway, which could be compromised without proper precautions.

📌Core Message

Always keep old trach ties in place until the new ones are secure to prevent tube dislodgement and maintain airway safety.

Answer 3

Correct Answers:

Decrease speaking speed.

Rationale :

👂Older adults may suffer from presbycusis, which makes it difficult to hear high-frequency or fast speech.

🗣Speaking slowly and clearly enhances word discrimination, which is more effective than shouting.

🚫Over-enunciating can distort pronunciation, making speech less comprehensible for those with hearing loss.

👁While nonverbal communication supports understanding, verbal clarity remains essential for conveying detailed information.

📌Core Message

Slowing speech enhances clarity for clients with hearing loss more effectively than shouting or exaggerating speech.

Answer 4

Correct Answers:

Replace the gauze with a transparent dressing.

Rationale :

🩹A stage 3 pressure injury with granulation tissue benefits from a moist healing environment provided by transparent dressings.

🌬Transparent dressings allow oxygen exchange, visual monitoring, and protect delicate healing tissue from trauma during changes.

🧼Leaving the wound open can expose it to infection, and over-frequent dressing changes can impair tissue repair.

🧪Hydrocolloid gels are often reserved for less granulated wounds and may not adhere well in heavily exudative wounds.

📌Core Message

Transparent dressings support moist wound healing and allow for monitoring while protecting granulating tissue.

Answer 5

Correct Answers:

Draw air in through nose and exhale slowly through pursed lips.

Rationale :

🌬Pursed-lip breathing helps prolong exhalation, which prevents airway collapse and improves oxygenation in emphysema.

💨This technique reduces air trapping, a common problem in obstructive lung diseases like COPD.

📉Rapid or shallow breathing increases work of breathing and may lead to hypoxemia or fatigue.

🧍Posture and arm position may assist ventilation, but controlled breathing is the most effective strategy for gas exchange.

📌Core Message

Pursed-lip breathing promotes controlled exhalation, reduces air trapping, and improves gas exchange in emphysema.

Answer 6

Correct Answers:

Escort the client to the cafeteria.

Rationale :

🚶Clients with Huntington’s disease often experience cognitive and motor impairment, making it difficult to follow directions or maps.

🧭Visual aids like maps or color codes are not sufficient due to the client’s disorientation or memory deficits.

👥Escorting the client ensures safety and reduces anxiety, especially in a new or complex environment.

🗣Verbal instructions may be forgotten quickly, increasing the risk of wandering or confusion.

📌Core Message

Clients with Huntington's disease benefit from direct assistance due to cognitive decline and risk of disorientation.

Answer 7

Correct Answers:

Auscultate the client's bowel sounds.

Rationale :

💊Hydromorphone, like other opioids, can significantly reduce gastrointestinal motility, leading to constipation or ileus.

👂Decreased or absent bowel sounds may indicate opioid-induced ileus, a potentially serious complication.

🧬While checking glucose or heart rate can be relevant in certain contexts, they are not primary concerns with opioid use.

🧠Monitoring GI function is especially critical in clients receiving regular opioid doses over multiple days.

📌Core Message

Opioids like hydromorphone can cause decreased GI motility, making bowel sound assessment essential.

Answer 8

Correct Answers:

Observe the client's fingers.

Rationale :

👋Early signs of rheumatoid arthritis include swelling, stiffness, and tenderness in small joints, especially the fingers.

🔍Visual inspection of these joints allows for early detection of inflammatory changes before nodules or deformities form.

🦠RA primarily affects joints—not the skin or lymph nodes—especially in the initial stages.

🧪Palpating large joints or lymph nodes may be useful later but doesn't detect early joint involvement.

📌Core Message

Early rheumatoid arthritis signs appear in the fingers, with joint swelling and tenderness as key indicators.

Answer 9

Correct Answers:

I should use this medication in its handihaler every day.

Rationale :

💨Tiotropium is a long-acting bronchodilator used as maintenance therapy for COPD, not for acute symptoms.

🕒It must be used daily in its specific HandiHaler device to provide consistent airway dilation.

🚫Using it for rescue in acute dyspnea or as-needed is ineffective and indicates a misunderstanding.

💊It doesn't significantly thin secretions; its primary role is to relax airway smooth muscles.

📌Core Message

Tiotropium is a daily-use, long-acting bronchodilator for maintenance of COPD symptoms, not rescue.

Answer 10

Correct Answers:

0.5

Rationale :

🧪The reconstituted concentration is 0.3 mg in 2 mL, resulting in 0.15 mg/mL.

📏To give 0.125 mg, divide dose by concentration: 0.125 ÷ 0.25 = 0.5 mL.

🧮This ensures accurate dosing of interferon beta-1b based on safe reconstitution protocols.

⚖Correctly calculating dose volume prevents underdosing or toxicity in clients with multiple sclerosis.

📌Core Message

Proper dose calculation ensures safe medication administration by adjusting for reconstitution concentration.

1 :
A client has been administered lactulose for several days. Which therapeutic response should the nurse expect for a client with hepatic encephalopathy?

2 :
A client who has had a laryngectomy and tracheostomy frequently expectorates copious amounts of purulent secretions. When changing the ties of the tracheostomy tube, which action is most important for the nurse to take?

3 :
An older female client is hospitalized with a fractured femur. During a routine nursing assessment, she repeatedly asks the nurse to "speak up" so that she can hear the questions. Which action is best for the nurse to take?

4 :
The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

5 :
The nurse is caring for a client with emphysema who is mildly dyspneic after ambulation. Which instruction should the nurse provide to the client to improve gas exchange?

6 :
Which approach is best for the nurse to use when directing a client with Huntington's disease to the hospital cafeteria?

7 :
The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?

8 :
Which technique should the nurse use when assessing for early signs of rheumatoid arthritis?

9 :
A client diagnosed with chronic obstructive pulmonary disease (COPD) is given a new prescription for tiotropium via an inhalation device. Which statement indicates that the client understands the instructions for using this medication?

1 : A client has been administered lactulose for several days. Which therapeutic response should the nurse expect for a client with hepatic encephalopathy?

2 : A client who has had a laryngectomy and tracheostomy frequently expectorates copious amounts of purulent secretions. When changing the ties of the tracheostomy tube, which action is most important for the nurse to take?

3 : An older female client is hospitalized with a fractured femur. During a routine nursing assessment, she repeatedly asks the nurse to "speak up" so that she can hear the questions. Which action is best for the nurse to take?

4 : The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

5 : The nurse is caring for a client with emphysema who is mildly dyspneic after ambulation. Which instruction should the nurse provide to the client to improve gas exchange?

6 : Which approach is best for the nurse to use when directing a client with Huntington's disease to the hospital cafeteria?

7 : The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?

8 : Which technique should the nurse use when assessing for early signs of rheumatoid arthritis?

9 : A client diagnosed with chronic obstructive pulmonary disease (COPD) is given a new prescription for tiotropium via an inhalation device. Which statement indicates that the client understands the instructions for using this medication?

1 :
A client has been administered lactulose for several days. Which therapeutic response should the nurse expect for a client with hepatic encephalopathy?

2 :
A client who has had a laryngectomy and tracheostomy frequently expectorates copious amounts of purulent secretions. When changing the ties of the tracheostomy tube, which action is most important for the nurse to take?

3 :
An older female client is hospitalized with a fractured femur. During a routine nursing assessment, she repeatedly asks the nurse to "speak up" so that she can hear the questions. Which action is best for the nurse to take?

4 :
The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

5 :
The nurse is caring for a client with emphysema who is mildly dyspneic after ambulation. Which instruction should the nurse provide to the client to improve gas exchange?

6 :
Which approach is best for the nurse to use when directing a client with Huntington's disease to the hospital cafeteria?

7 :
The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?

8 :
Which technique should the nurse use when assessing for early signs of rheumatoid arthritis?

9 :
A client diagnosed with chronic obstructive pulmonary disease (COPD) is given a new prescription for tiotropium via an inhalation device. Which statement indicates that the client understands the instructions for using this medication?