A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath and a productive cough with thickened, tenacious mucus. The client reports difficulty walking up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self-care?
Teach anxiety reduction methods for feelings of suffocation.
Increase the daily intake of oral fluids to liquefy secretions.
Call the clinic if undesirable side effects of medications occur.
Avoid crowded enclosed areas to reduce pathogen exposure.
The Correct Answer is B
Choice A rationale
Teaching anxiety reduction methods for feelings of suffocation is important but not the most immediate action needed to address the client’s respiratory symptoms.
Choice B rationale
Increasing the daily intake of oral fluids to liquefy secretions is the most important action for the nurse to instruct the client about self-care. This helps to thin the mucus, making it easier to expectorate and improving breathing.
Choice C rationale
Calling the clinic if undesirable side effects of medications occur is important but not the most immediate action needed to address the client’s respiratory symptoms.
Choice D rationale
Avoiding crowded enclosed areas to reduce pathogen exposure is important but not the most immediate action needed to address the client’s respiratory symptoms.
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Correct Answer is A
Explanation
Choice A rationale
Lactulose is a synthetic sugar used to treat hepatic encephalopathy by reducing the absorption of ammonia in the intestines. Ammonia is a neurotoxin that can impair mental status in patients with liver dysfunction. By decreasing ammonia levels, lactulose helps improve cognitive function and mental status in patients with hepatic encephalopathy.
Choice B rationale
While lactulose can cause diarrhea as a side effect, the therapeutic goal in hepatic encephalopathy is not to reduce the number of liquid stools but to lower ammonia levels in the blood. The reduction in ammonia levels leads to improved mental status, not necessarily a reduction in liquid stools.
Choice C rationale
The ability to ambulate independently is not a direct therapeutic response to lactulose. The primary goal of lactulose therapy in hepatic encephalopathy is to improve mental status by reducing ammonia levels, not to enhance physical mobility.
Choice D rationale
Lactulose does not have a direct effect on urine output. Its primary mechanism of action is to reduce ammonia absorption in the intestines, thereby improving mental status in patients with hepatic encephalopathy.
Correct Answer is A
Explanation
Choice A rationale
Reported history of alcoholism is the most important assessment finding to address before administering terbinafine HCL. Terbinafine is metabolized by the liver, and clients with a history of alcoholism may have impaired liver function, increasing the risk of hepatotoxicity. Monitoring liver function and assessing for signs of liver damage are crucial before starting treatment.
Choice B rationale
Toenails appear thick and yellow is a common symptom of fungal toenail infection, but it is not the most critical assessment finding to address before administering terbinafine HCL. The focus should be on assessing liver function.
Choice C rationale
Employed as a construction worker is not the most critical assessment finding to address before administering terbinafine HCL. While occupational exposure to fungi may be relevant, the primary concern is liver function.
Choice D rationale
White blood cell count of 8,500/mm³ (8.5 x 10⁹/L) is within the normal range and is not the most critical assessment finding to address before administering terbinafine HCL. The primary concern is liver function.