Correct Answer: A

Rationale: Lactulose is the most effective nursing intervention in preventing and managing hepatic encephalopathy in patients with cirrhosis. Lactulose works by promoting the elimination of ammonia in the colon through its laxative effect, thereby reducing ammonia levels in the blood. High ammonia levels are associated with the development of hepatic encephalopathy. By administering lactulose as prescribed, nurses can help reduce the risk of encephalopathy and manage symptoms effectively. Monitoring serum ammonia levels is important in assessing the effectiveness of lactulose therapy, but administering lactulose is the primary nursing intervention in this situation. Dietary protein restriction is also commonly recommended; however, lactulose administration is the most vital intervention in this scenario. Additionally, encouraging increased fluid intake is important for overall liver health but is not as specific to preventing and managing hepatic encephalopathy as administering lactulose.

Correct Answer: A

Rationale: In prioritizing nursing diagnoses, the nurse should consider issues that pose the greatest risk to the patient's immediate well-being. A fluid volume deficit can lead to dehydration and potentially life-threatening complications, making it a priority to address. It is crucial to restore fluid balance to maintain normal body functions and prevent further deterioration of the patient's condition. Ensuring adequate hydration is essential for the patient's overall health and recovery. The other options, such as risk for pain, coping, and body image disturbances, while important, are not as urgent as addressing a fluid volume deficit.

Correct Answer: A

Rationale: The incident report is the best source of factual information to investigate the fall further. Incident reports are official documents that provide a detailed account of what happened leading up to and during an incident. They include factual information such as the date, time, location, individuals involved, and details of the event. By reviewing the incident report, investigators can gather accurate information to determine the cause of the fall and any contributing factors. This document serves as an essential tool in conducting a thorough investigation into the fall and helps in identifying preventive measures to avoid similar incidents in the future.

Correct Answer: D

Rationale: Nephrolithiasis refers to the formation of stones within the kidney or urinary tract. The most common types of kidney stones are either composed of calcium oxalate or calcium phosphate. When these stones form within the renal collecting system, they can lead to symptoms such as flank pain, hematuria, and urinary obstruction. Ureteropelvic junction (UPJ) obstruction and ureterovesical junction (UVJ) obstruction are specific types of blockages within the urinary system that can be caused by kidney stones but are not characteristic of the stone formation itself. Renal colic is the term used to describe the severe pain associated with the passage of a kidney stone through the ureter.

Correct Answer: B

Rationale: When a patient is in skin traction, the constant pressure and rubbing against the skin from the traction device can lead to skin breakdown. Therefore, assessing for signs of skin breakdown, such as redness, irritation, or pressure injuries, is crucial to prevent complications and ensure the patient's comfort and safety. Prompt identification and intervention for any skin issues can prevent further damage and promote healing, making this the priority intervention for quality nursing care in skin traction. While monitoring for signs of infection, urinary incontinence, and bowel sounds are important, skin breakdown poses a more immediate threat to the patient's well-being in this scenario.