Nokea
A client with a history of heart failure is prescribed torsemide (Demadex). The nurse should monitor the client for which of the following adverse effects?
- A. Hypokalemia.
- B. Hypernatremia.
- C. Hypermagnesemia.
- D. Hypercalcemia.
Correct Answer: A
Rationale: Torsemide, a loop diuretic, can cause hypokalemia.
You may also like to solve these questions
The nurse monitors the serum electrolyte levels of a client who is taking digoxin (Lanoxin). Which of the following electrolyte imbalances is a common cause of digoxin toxicity?
- A. Hyponatremia.
- B. Hypomagnesemia.
- C. Hypocalcemia.
- D. Hypokalemia.
Correct Answer: D
Rationale: Hypokalemia enhances digoxin's effect on the heart, increasing toxicity risk by altering cardiac membrane potential.
Which of the following is the most accurate method of determining the extent of a client's fluid loss?
- A. Measuring intake and output
- B. Assessing vital signs
- C. Weighing the client
- D. Assessing skin turgor
Correct Answer: C
Rationale: Daily weighing is the most accurate method to assess fluid loss, as 1 kg of weight loss corresponds to 1 liter of fluid loss. Intake/output, vital signs, and skin turgor are less precise.
The nurse is caring for a client post-laparoscopic cholecystectomy. Which discharge instruction is most important?
- A. Resume normal diet immediately
- B. Report fever or yellowing of skin
- C. Avoid bathing for 2 weeks
- D. Lift heavy objects as tolerated
Correct Answer: B
Rationale: Fever or jaundice post-cholecystectomy may indicate complications like infection or bile duct injury, requiring immediate reporting.
A client with a history of cystitis is admitted to the hospital with a diagnosis of pyelonephritis. The nurse should assess the client for which of the following?
- A. Suprapubic pain.
- B. Dysuria.
- C. Urine retention.
- D. Costovertebral tenderness.
Correct Answer: D
Rationale: Costovertebral tenderness is a hallmark of pyelonephritis, indicating kidney involvement, unlike the other symptoms, which are more typical of cystitis.
The nurse has assisted the primary health care provider in placing a central (subclavian) catheter. Which priority action should the nurse take after the procedure?
- A. Ensure that a chest radiograph is done.
- B. Obtain a temperature reading to monitor for infection.
- C. Label the dressing with the date and time of catheter insertion.
- D. Monitor the blood pressure (BP) to check for fluid volume overload.
Correct Answer: A
Rationale: A major risk associated with central catheter insertion is the possibility of a pneumothorax developing from an accidental puncture of the lung. Obtaining a chest radiograph and checking the results is the best method to determine if this complication has occurred and verify catheter tip placement before initiating intravenous (IV) therapy. Although a client may develop an infection at the central catheter site, a temperature elevation would not likely occur immediately after placement. Labeling the dressing site is important, but it is not a priority action in this situation. Although BP assessment is always important in checking a client's status after an invasive procedure, fluid volume overload is not a concern until IV fluids are started.