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 reduces systemic ammonia by trapping it in the colon and promoting its excretion, which is critical in treating hepatic encephalopathy.

💠 Ammonia buildup in the bloodstream impairs cerebral function, causing confusion and altered mental status.

💠 By reducing ammonia, lactulose improves neurocognitive function, including memory, alertness, and orientation.

💠 A therapeutic response is evident when the client shows increased mental clarity or alertness.

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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.

💠 Keeping the old ties in place ensures the tube remains stabilized while securing the new ones.

💠 Removing the old ties prematurely can lead to dislodgement, which is a life-threatening complication.

💠 Safe practice involves securing the new ties first, then removing the old ones.

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Answer 3

Correct Answers:

Decrease speaking speed.

Rationale :

💠 Age-related hearing loss (presbycusis) often involves difficulty understanding rapid speech, not necessarily low volume.

💠 Speaking slowly, clearly, and distinctly aids comprehension without overwhelming the client.

💠 Shouting distorts speech sounds and may further confuse the client.

💠 The goal is to enhance verbal clarity and promote effective communication.

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Answer 4

Correct Answers:

Replace the gauze with a transparent dressing.

Rationale :

💠 Transparent dressings protect the wound while allowing visual inspection without removing the dressing.

💠 For a Stage 3 pressure injury with granulation, this type of dressing supports moist wound healing and minimizes trauma during dressing changes.

💠 Gauze may adhere to granulation tissue and disrupt healing.

💠 Transparent film is non-adherent and maintains a healing environment.

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Answer 5

Correct Answers:

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

Rationale :

💠 Pursed-lip breathing slows exhalation, reduces airway collapse, and promotes CO₂ elimination, which is key for clients with emphysema.

💠 It improves gas exchange by increasing expiratory time and keeping airways open.

💠 This breathing technique relieves dyspnea and anxiety related to shortness of breath.

💠 It also lowers respiratory rate and enhances oxygenation after activity.

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Answer 6

Correct Answers:

Escort the client to the cafeteria.

Rationale :

💠 Clients with Huntington’s disease often experience cognitive decline and difficulty with navigation and decision-making.

💠 Escorting the client ensures safety, prevents disorientation, and respects the individual's dignity.

💠 Even with orientation aids, clients may struggle with memory and judgment.

💠 Direct supervision reduces the risk of getting lost or unsafe wandering.

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Answer 7

Correct Answers:

Auscultate the client's bowel sounds.

Rationale :

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

💠 Regular bowel assessments are vital to detect early signs of GI complications.

💠 Absent or hypoactive bowel sounds may indicate the need to adjust pain management plans or initiate bowel protocols.

💠 Early detection can prevent severe complications like bowel obstruction.

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Answer 8

Correct Answers:

Observe the client's fingers.

Rationale :

💠 Early signs of rheumatoid arthritis (RA) typically appear in the small joints of the hands and fingers, including swelling, redness, and deformities.

💠 These changes are bilateral and symmetrical, distinguishing RA from other forms of arthritis.

💠 Prompt detection allows for early intervention, slowing disease progression.

💠 Joint observation is more indicative of RA than generalized symptoms.

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Answer 9

Correct Answers:

I should use this medication in its handihaler every day.

Rationale :

💠 Tiotropium is a long-acting anticholinergic used for daily maintenance therapy in COPD.

💠 It helps to prevent bronchospasms, not to relieve acute symptoms.

💠 The HandiHaler device ensures proper inhalation of the dry powder form.

💠 Consistent daily use helps improve baseline lung function over time.

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Answer 10

Correct Answers:

0.5

Rationale :

💠 Reconstituted solution: 0.3 mg in 2 mL, so concentration = 0.3 mg / 2 mL = 0.15 mg/mL.

💠 Required dose: 0.125 mg, so volume = 0.125 mg ÷ 0.25 mg/mL = 0.5 mL.

💠 Accurate dosing ensures therapeutic effect while preventing overdose.

💠 Always use standard dosage formulas and verify vial instructions.

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Hesi RN Adulth Health 1 Exam II

No.

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?

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Hesi RN Adulth Health 1 Exam II

No.

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?