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A client with chronic heart failure is prescribed spironolactone. The nurse should monitor for which potential side effect?
- A. Hyperkalemia
- B. Hypokalemia
- C. Hypernatremia
- D. Hyponatremia
Correct Answer: A
Rationale: The correct answer is A: Hyperkalemia. Spironolactone is a potassium-sparing diuretic that can lead to an excess of potassium in the body, resulting in hyperkalemia. This side effect is important to monitor in clients taking spironolactone, especially those with chronic heart failure, as hyperkalemia can lead to serious cardiac complications.
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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.
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 with a diagnosis of schizophrenia is prescribed aripiprazole. The nurse should monitor the client for which potential side effect?
- A. Weight gain
- B. Dry mouth
- C. Headache
- D. Increased appetite
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What information should the practical nurse provide to a female client who started taking an oral sulfonamide for a urinary tract infection the previous day and reports slight anorexia, while also experiencing urinary frequency?
- A. Take the medication with an antacid instead of cranberry juice to reduce the anorexia.
- B. Continue to take the medication with a sip of cranberry juice, restricting fluids until the frequency is controlled.
- C. Continue to drink cranberry juice, but take the medicine on an empty stomach with a full glass of water.
- D. Take the medication with a spoonful of ice cream or applesauce and avoid drinking cranberry juice.
Correct Answer: C
Rationale: The practical nurse should advise the client to take sulfonamides with a full glass of water to help prevent crystalluria. It is essential to take the medication on an empty stomach, ideally 1 hour before eating or 2 hours after eating to maximize its absorption and effectiveness. Continuing to drink cranberry juice is beneficial, but it is important to take the medicine separately to enhance its therapeutic action.
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.