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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Which assessment finding requires nursing intervention prior to the administration of medication?
- A. Apical pulse heard best at the pulmonic site
- B. Irregular apical pulse rhythm
- C. Presence of a systolic heart murmur
- D. Apical pulse rate of 50 beats/minute
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with a diagnosis of depression is prescribed fluoxetine. Which statement by the client indicates the need for further teaching?
- A. I should take this medication in the morning with food.
- B. It may take 1 to 4 weeks to notice improvement in symptoms.
- C. I can stop taking this medication once I feel better.
- D. This medication might make me feel drowsy.
Correct Answer: C
Rationale: The correct answer is C. Clients prescribed fluoxetine should not stop taking the medication once they feel better without consulting their healthcare provider. It is essential to complete the full course of treatment as directed by the healthcare provider to prevent relapse or potential worsening of symptoms. Abruptly stopping fluoxetine can lead to withdrawal symptoms and may not effectively manage the condition. Therefore, it is crucial for clients to follow the healthcare provider's guidance regarding the duration of treatment with fluoxetine.
A client with chronic kidney disease is prescribed calcium acetate. The nurse should monitor for which potential side effect?
- A. Hypercalcemia
- B. Hypocalcemia
- C. Hyperkalemia
- D. Hypokalemia
Correct Answer: A
Rationale: When a client with chronic kidney disease is prescribed calcium acetate, the nurse must monitor for hypercalcemia, not hypocalcemia, hyperkalemia, or hypokalemia. Calcium acetate can increase calcium levels in the blood, leading to hypercalcemia. Symptoms of hypercalcemia include fatigue, confusion, constipation, and muscle weakness. Regular monitoring of calcium levels is crucial to prevent complications associated with elevated calcium levels.
Which nursing intervention is most important when caring for a client receiving aspirin 600mg po QID?
- A. Monitor temperature q4h
- B. Use 10-point pain scale to assess pain
- C. Assess for dyspepsia and nausea
- D. Check stool for occult blood
Correct Answer: D
Rationale: The correct answer is to check the stool for occult blood when caring for a client receiving aspirin 600mg po QID. Aspirin can lead to gastrointestinal bleeding, and checking for occult blood in the stool is essential to monitor for this serious adverse effect. Monitoring temperature, assessing pain, and checking for dyspepsia and nausea are important interventions but not as critical as monitoring for gastrointestinal bleeding when a client is receiving aspirin.
A client who was diagnosed with oral thrush calls the clinic saying the medication bottle broke and all of the medication was spilled. The client is requesting a refill order. The nurse should contact the health care provider about a refill for which medication?
- A. Ampicillin
- B. Ciprofloxacin
- C. Neomycin sulfate
- D. Nystatin
Correct Answer: D
Rationale: Nystatin is the appropriate medication for treating oral thrush as it is an antifungal drug specifically used for fungal infections. It targets the fungus responsible for thrush, Candida, effectively. Therefore, the nurse should contact the healthcare provider to request a refill of Nystatin for the client.