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A client with heart failure (HF) develops hyperaldosteronism and spironolactone is prescribed. Which instruction should the nurse include in this client’s plan of care?
- A. Replace salt with a salt substitute.
- B. Cover your skin before going outside.
- C. Limit intake of high-potassium foods.
- D. Monitor skin for excessive bruising.
Correct Answer: C
Rationale: Spironolactone, a potassium-sparing diuretic, can cause hyperkalemia. Limiting high-potassium foods (C) prevents this risk. Salt substitutes (A) often contain potassium, worsening hyperkalemia. Sun protection (B) and bruising (D) are unrelated to spironolactone’s primary risks.
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The nurse administers naloxone to a patient with opioid-induced respiratory depression. An hour later, the nurse finds the patient has a respiratory rate of 4 breaths/minute, oxygen saturation of 75%, and is unresponsive. What action should the nurse take?
- A. Administer a second dose of naloxone.
- B. Prepare to assist with chest tube insertion.
- C. Determine Glasgow Coma Scale score.
- D. Initiate cardiopulmonary resuscitation (CPR).
Correct Answer: D
Rationale: Severe respiratory depression (4 breaths/min), hypoxia (75% SpO₂), and unresponsiveness require immediate CPR (D) to restore circulation/oxygenation. A second naloxone dose (A) may be needed but is secondary. Chest tubes (B) are irrelevant. Glasgow scoring (C) delays critical intervention.
A nurse is caring for a client diagnosed with stage 4 cancer who has a prescription for a subcutaneous morphine sulfate patch for pain. The client is short of breath and difficult to arouse. During a head-to-toe assessment, the nurse finds four patches on the client’s body. What should be the nurse’s first action?
- A. Administer a narcotic reversal drug.
- B. Apply an oxygen face mask.
- C. Remove the morphine patches.
- D. Monitor the client’s blood pressure.
Correct Answer: C
Rationale: Four morphine patches suggest overdose, causing respiratory depression and sedation. Removing the patches (C) stops further absorption. Naloxone (A) or oxygen (B) may follow, but removal is first. Blood pressure monitoring (D) is secondary.
A patient is currently on an oral contraceptive and has been prescribed erythromycin. What advice should the nurse provide to the patient?
- A. Utilize an additional form of contraception.
- B. Immediately discontinue the oral contraceptive.
- C. Ensure a 12-hour gap between taking the medications.
- D. Avoid prolonged exposure to direct sunlight.
Correct Answer: A
Rationale: Erythromycin may reduce oral contraceptive efficacy by inducing hepatic metabolism. Using an additional contraceptive method (A) prevents unintended pregnancy. Discontinuing the contraceptive (B) is unnecessary. Timing gaps (C) don’t mitigate the interaction. Sunlight avoidance (D) relates to other antibiotics like tetracycline.
The nurse administers risedronate to a client with osteoporosis at 0700. The client asks for a glass of milk to drink with the medication. What action should the nurse take?
- A. Instruct the client that it is necessary to take nothing but water with the medication.
- B. Withhold the medication until the client’s breakfast tray is available on the unit.
- C. Consult with a pharmacist about scheduling the dose one hour after the client eats.
- D. Assign an unlicensed assistive personnel (UAP) to bring the client a glass of low-fat milk.
Correct Answer: A
Rationale: Risedronate, a bisphosphonate, must be taken with plain water on an empty stomach, 30 minutes before food or other beverages, to ensure optimal absorption. Milk (B) contains calcium, reducing absorption. Delaying until breakfast (C) violates timing requirements. Consulting a pharmacist (D) is unnecessary, as administration guidelines are clear.
The nurse is administering sodium polystyrene sulfonate to a client with acute kidney injury (AKI). Which laboratory finding indicates that the medication has been effective?
- A. Serum potassium level of 3.8 mEq/L (3.8 mmol/L)
- B. Hemoglobin level of 13.5 g/dL (135 g/L).
- C. Serum glucose level of 120 mg/dL (6.7 mmol/L)
- D. Serum ammonia level of 30 Mcg/dL (17.62 Mermol/L)
Correct Answer: A
Rationale: Sodium polystyrene sulfonate treats hyperkalemia by exchanging sodium for potassium. A potassium level of 3.8 mEq/L (A) indicates effectiveness (normal range: 3.5-5.0 mEq/L). Hemoglobin (B), glucose (C), and ammonia (D) are unrelated to its action.