Difficulty: Medium
Average Score: 95%
Simulated
A client with cirrhosis is scheduled to receive a third dose of lactulose (Cephulac) at 1800. Which current finding would cause the nurse to question administering this medication?
Correct answer
D
Rationale
Breath with fecal odor could indicate hepatic encephalopathy, for which lactulose is indicated. Increasing confusion is a symptom of hepatic encephalopathy suggests a need for lactulose. Elevated ammonia levels indicate hepatic encephalopathy hence the need for lactulose. If the client already has diarrhea, additional doses of lactulose (which acts as a laxative) could exacerbate this condition and might need to be adjusted or halted based on clinical judgment.