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A client with a history of heart failure is prescribed spironolactone. The nurse should monitor for which potential side effect?
- A. Hyperkalemia
- B. Hypokalemia
- C. Hyponatremia
- D. Hypernatremia
Correct Answer: A
Rationale: The correct answer is A: Hyperkalemia. Spironolactone is a potassium-sparing diuretic, which can lead to an excess of potassium in the body, causing hyperkalemia. This medication inhibits the action of aldosterone, leading to decreased potassium excretion and potential retention. Monitoring potassium levels is essential to prevent complications such as cardiac arrhythmias, especially in clients with heart failure.
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A client with a diagnosis of schizophrenia is prescribed olanzapine. The nurse should monitor the client for which potential side effect?
- A. Weight gain
- B. Dry mouth
- C. Hair loss
- D. Headache
Correct Answer: A
Rationale: The correct answer is A: Weight gain. Olanzapine is known to cause weight gain as a common side effect. This weight gain can increase the risk of metabolic issues such as diabetes and dyslipidemia. Monitoring the client's weight regularly is essential to detect and address any weight changes promptly.
A client with a diagnosis of bipolar disorder is prescribed quetiapine. The nurse should monitor for which potential adverse effect?
- A. Weight gain
- B. Hair loss
- C. Insomnia
- D. Tremors
Correct Answer: A
Rationale: When a client with bipolar disorder is prescribed quetiapine, the nurse should monitor for weight gain as a potential adverse effect. Quetiapine is known to commonly cause weight gain, which can have implications for the client's overall health. Regular monitoring of weight can help in early detection and management of this side effect.
A postoperative client has a prescription for ketorolac 30mg IV q6h. Which response demonstrates that therapeutic levels of the medication have been achieved?
- A. Observe wound drainage for a change in appearance
- B. Assess the client's calves for inflammation
- C. Perform a pain assessment using a numeric scale
- D. Measure the client's intake and output
Correct Answer: C
Rationale: The correct response is to perform a pain assessment using a numeric scale. Ketorolac is an NSAID prescribed for pain relief. Monitoring pain levels is crucial to evaluate the therapeutic effectiveness of the medication. Pain assessment helps determine if the medication is providing adequate pain relief, indicating that therapeutic levels have been achieved.
A client with a diagnosis of schizophrenia is prescribed risperidone. The nurse should monitor the client for which potential side effect?
- A. Weight gain
- B. Dry mouth
- C. Nausea
- D. Headache
Correct Answer: A
Rationale: When a client is prescribed risperidone, it is essential to monitor for potential side effects. Weight gain is a common side effect of risperidone, so the nurse should closely monitor the client's weight throughout the treatment. This monitoring helps in early detection of weight changes and allows for timely interventions to prevent further complications.
The practical nurse administers lactulose to a client. Which client outcome would indicate a therapeutic response?
- A. An increase in urine output
- B. Two to three soft stools per day
- C. Absence of nausea
- D. Decreased serum potassium
Correct Answer: B
Rationale: Lactulose is a type of laxative that works by preventing the absorption of ammonia in the colon, leading to increased water absorption in the stool and softening of the stool. The therapeutic response to lactulose is indicated by the passage of two to three soft stools per day, showing that the medication is effectively promoting bowel movements.