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A client with a history of heart failure is prescribed spironolactone (Aldactone). Which electrolyte imbalance should the nurse monitor for?
- A. Hypokalemia
- B. Hyperkalemia
- C. Hyponatremia
- D. Hypercalcemia
Correct Answer: B
Rationale: Spironolactone, a potassium-sparing diuretic, can cause hyperkalemia, requiring monitoring to prevent arrhythmias.
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The nurse is planning to teach the client how to properly use a metered-dose inhaler to treat asthma. Which of the following instructions should be included in the teaching?
- A. Rinse the mouth after each use of a steroid inhaler.
- B. Inhale quickly when administering the medication.
- C. Inhale the medication and then exhale through the nose.
- D. Cough and deep-breathe before inhaling the medication.
Correct Answer: A
Rationale: Rinsing the mouth after using a steroid inhaler prevents oral thrush, a common side effect. Quick inhalation, nasal exhalation, or coughing before use are not standard techniques.
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.
The nurse assesses the assigned clients for the shift. Of the following assigned clients, which client is at greatest risk for falling?
- A. A 22-year-old man with three fractured ribs and a fractured left arm.
- B. A 70-year-old woman with episodes of syncope.
- C. A 50-year-old man with angina.
- D. A 30-year-old woman with a fractured ankle.
Correct Answer: B
Rationale: Syncope increases fall risk due to sudden loss of consciousness, particularly in an elderly client with potential comorbidities.
The nurse is teaching a client with a new diagnosis of hypertension about lifestyle modifications. Which of the following recommendations is most effective?
- A. Increase calcium intake.
- B. Reduce alcohol consumption.
- C. Limit protein intake.
- D. Avoid potassium-rich foods.
Correct Answer: B
Rationale: Reducing alcohol consumption lowers blood pressure by decreasing vascular resistance and fluid retention.
The nurse is caring for a client who has just undergone a tonsillectomy. Which of the following interventions is most important in the immediate postoperative period?
- A. Encourage frequent swallowing.
- B. Monitor for excessive swallowing.
- C. Offer ice chips immediately.
- D. Keep the head of the bed flat.
Correct Answer: B
Rationale: Monitoring for excessive swallowing is critical post-tonsillectomy, as it may indicate bleeding from the surgical site.