HESI RN
HESI RN Med Surg Questions
Extract:
Question 1 of 5
Lactulose was prescribed two days ago for a client who was recently diagnosed with hepatic encephalopathy. The client is confused and experiencing frequent loose stools. Laboratory findings show an elevated serum ammonia (NH) level of 220 μg/dL (157.1 μmol/dL). Which action should the nurse take?
Correct Answer: B
Rationale: Lactulose reduces ammonia levels by promoting its excretion, and the elevated ammonia level indicates the need to continue therapy. Loose stools are an expected effect, and continuing the dose addresses the underlying hepatic encephalopathy.
Question 2 of 5
Lactulose was prescribed two days ago for a client who was recently diagnosed with hepatic encephalopathy. The client is confused and experiencing frequent loose stools. Laboratory findings show an elevated serum ammonia (NH) level of 220 μg/dL (157.1 μmol/dL). Which action should the nurse take?
Correct Answer: B
Rationale: Lactulose reduces ammonia levels by promoting its excretion, and the elevated ammonia level indicates the need to continue therapy. Loose stools are an expected effect, and continuing the dose addresses the underlying hepatic encephalopathy.
Question 3 of 5
An infant born 2 days ago has not passed a meconium stool and begins to vomit bilious secretions. Which action should the nurse take first?
Correct Answer: B
Rationale: Gathering IV supplies addresses the risk of dehydration and shock from vomiting and possible bowel obstruction, which is the priority. Other actions are less urgent.
Question 4 of 5
Lactulose was prescribed two days ago for a client who was recently diagnosed with hepatic encephalopathy. The client is confused and experiencing frequent loose stools. Laboratory findings show an elevated serum ammonia (NH) level of 220 μg/dL (157.1 μmol/dL). Which action should the nurse take?
Correct Answer: B
Rationale: Lactulose reduces ammonia levels by promoting its excretion, and the elevated ammonia level indicates the need to continue therapy. Loose stools are an expected effect, and continuing the dose addresses the underlying hepatic encephalopathy.
Question 5 of 5
The nurse is preparing to administer medications for an eight-month-old infant with heart failure. The infant has a blood pressure of 114/66 mm Hg, apical pulse of 88 beats/minute, and respirations of 30 breaths/minute. Which medication should the nurse withhold until the health care provider is notified?
Correct Answer: B
Rationale: Digoxin is withheld if the apical pulse is below 90 beats/minute in infants to prevent toxicity. Other medications are not contraindicated.