Nokea
A client is receiving spironolactone (Aldactone) for treatment of bilateral lower extremity edema. The nurse should instruct the client to make which of the following nutritional modifications to prevent an electrolyte imbalance?
- A. Increase intake of milk and milk products.
- B. Restrict fluid intake to 1000 mL per day.
- C. Decrease foods high in potassium.
- D. Decrease foods high in sodium.
Correct Answer: C
Rationale: Spironolactone is a potassium-sparing diuretic, so decreasing potassium-rich foods prevents hyperkalemia. Sodium restriction may help edema but is less critical for electrolyte balance in this context.
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The nurse is assessing a client with a suspected hip fracture. Which of the following findings is most likely to be present?
- A. External rotation of the affected leg.
- B. Increased range of motion in the hip.
- C. Absence of pain on weight-bearing.
- D. Symmetrical leg lengths.
Correct Answer: A
Rationale: External rotation of the affected leg is a common sign of a hip fracture due to muscle and bone displacement.
A client admitted with a gastric ulcer has been vomiting bright red blood. His hemoglobin level is 5.11 g/dL, and his blood pressure is 100/50 mm Hg. The client and his family state that their religious beliefs do not support the use of blood products and refuse blood transfusions as a treatment for the bleeding. The nurse should collaborate with the physician and family to next:
- A. Discontinue all measures.
- B. Notify the hospital attorney.
- C. Attempt to stabilize the client through the use of fluid replacement.
- D. Give enough blood to keep the client from dying.
Correct Answer: C
Rationale: Respecting the client's religious beliefs, the nurse should focus on stabilizing the client with fluid replacement to address hypovolemia, as blood transfusions are refused.
The nurse is caring for a client with a history of atrial fibrillation who is prescribed amiodarone (Cordarone). Which of the following side effects should the nurse monitor for?
- A. Pulmonary toxicity.
- B. Hyperglycemia.
- C. Weight gain.
- D. Hair loss.
Correct Answer: A
Rationale: Amiodarone can cause pulmonary toxicity, a serious side effect requiring regular monitoring of lung function.
The nurse is caring for a client with a history of burns. Which of the following interventions should be included in the plan of care? Select all that apply.
- A. Monitor urine output.
- B. Administer tetanus prophylaxis.
- C. Provide psychological support.
- D. Restrict visitors to prevent infection.
- E. Apply cold compresses to burns.
Correct Answer: A, B, C
Rationale: Monitoring urine output, tetanus prophylaxis, and psychological support are essential. Visitors should be screened, not restricted, and cold compresses are contraindicated.
When a client has a tearing of tissue with irregular wound edges, the nurse should document this as:
- A. Contusion
- B. Abrasion
- C. Laceration
- D. Colonization
Correct Answer: C
Rationale: A laceration is characterized by tearing of tissue with irregular wound edges. Contusions are bruises, abrasions are superficial, and colonization refers to bacterial presence, not wound type.