Nokea
A client with a history of heart failure is prescribed spironolactone (Aldactone). The nurse should monitor the client for which of the following electrolyte imbalances?
- A. Hypokalemia.
- B. Hyperkalemia.
- C. Hyponatremia.
- D. Hypercalcemia.
Correct Answer: B
Rationale: Spironolactone, a potassium-sparing diuretic, can cause hyperkalemia, requiring close monitoring.
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A client with a history of asthma reports increased wheezing. Which medication should the nurse prepare to administer?
- A. Prednisone.
- B. Albuterol.
- C. Montelukast.
- D. Cromolyn sodium.
Correct Answer: B
Rationale: Albuterol, a short-acting beta-agonist, is the first-line treatment for acute asthma exacerbations to relieve bronchospasm.
The nurse developing a plan of care for a postterm small-for-gestational-age (SGA) newborn should identify which assessment as the priority to monitor?
- A. Urinary output
- B. Blood glucose levels
- C. Total bilirubin levels
- D. Hemoglobin and hematocrit
Correct Answer: B
Rationale: The most common metabolic complication in the SGA newborn is hypoglycemia, which can produce central nervous system abnormalities and mental retardation if not corrected immediately. Urinary output, although important, is not the highest priority action; however, the postterm SGA newborn is typically dehydrated from placental dysfunction. Hemoglobin and hematocrit levels are monitored because the postterm SGA newborn exhibits polycythemia, although this also does not require immediate attention. The polycythemia contributes to increased bilirubin levels, usually beginning on the second day after delivery.
A client with a history of chronic heart failure is prescribed digoxin (Lanoxin). The nurse should monitor the client for which of the following signs of toxicity? Select all that apply.
- A. Nausea.
- B. Visual disturbances.
- C. Tachycardia.
- D. Fatigue.
- E. Hypokalemia.
Correct Answer: A, B, D
Rationale: Digoxin toxicity presents with nausea, visual disturbances (e.g., yellow vision), and fatigue. Hypokalemia increases toxicity risk but is not a symptom.
The nurse is reviewing the laboratory results of a client with hypothyroidism. An expected finding is:
- A. Decreased thyroxine (T4) and increased thyroid-stimulating hormone (TSH) levels
- B. Decreased TSH and increased T4 levels
- C. Decreased creatine phosphokinase levels
- D. Absence of antithyroid antibodies
Correct Answer: A
Rationale: Hypothyroidism is characterized by decreased thyroxine (T4) and increased TSH as the pituitary attempts to stimulate the thyroid. Other options are inconsistent with hypothyroidism.
A client with a diagnosis of chronic heart failure is prescribed digoxin (Lanoxin). The nurse should monitor the client for which of the following signs of toxicity?
- A. Tachycardia.
- B. Yellow vision.
- C. Weight gain.
- D. Dry cough.
Correct Answer: B
Rationale: Yellow vision is a classic sign of digoxin toxicity, indicating the need for immediate evaluation.