Nokea
A client with liver cirrhosis and ascites is being treated with spironolactone. What is a key nursing consideration for this medication?
- A. Monitoring for signs of hyperkalemia
- B. Checking for signs of hypoglycemia
- C. Assessing for signs of dehydration
- D. Observing for symptoms of hyponatremia
Correct Answer: A
Rationale: The correct answer is A: Monitoring for signs of hyperkalemia. Spironolactone is a potassium-sparing diuretic commonly used in clients with liver cirrhosis and ascites. The key nursing consideration is monitoring potassium levels due to the risk of hyperkalemia, as spironolactone reduces potassium excretion. Hyperkalemia can lead to serious cardiac arrhythmias. Checking for hypoglycemia (B) is not directly related to spironolactone use. Assessing for dehydration (C) is important but not the key consideration for this medication. Observing for hyponatremia (D) is not a common side effect of spironolactone.
You may also like to solve these questions
A client has been diagnosed with an esophageal diverticulum after undergoing diagnostic imaging. When taking the health history, the nurse should expect the client to describe what sign or symptom?
- A. Burning pain on swallowing
- B. Regurgitation of undigested food
- C. Symptoms mimicking a myocardial infarction
- D. Chronic parotid abscesses
Correct Answer: B
Rationale: Rationale for Correct Answer B (Regurgitation of undigested food):
1. Esophageal diverticulum is a pouch-like protrusion in the esophageal wall, causing difficulty in swallowing.
2. Due to the diverticulum, food may get trapped and regurgitated, leading to regurgitation of undigested food.
3. This symptom is characteristic of esophageal diverticulum and indicates an abnormality in the esophageal functioning.
Summary of Incorrect Choices:
A: Burning pain on swallowing - Not a typical symptom of esophageal diverticulum; more indicative of conditions like GERD.
C: Symptoms mimicking a myocardial infarction - Unrelated to esophageal diverticulum and more suggestive of cardiac issues.
D: Chronic parotid abscesses - Not associated with esophageal diverticulum, as parotid abscesses involve the salivary glands.
When planning care for a 16-year-old with appendicitis presenting with right lower quadrant pain, what should the nurse prioritize as a nursing diagnosis?
- A. Imbalanced nutrition: Less than body requirements related to decreased oral intake
- B. Risk for infection related to possible rupture of the appendix
- C. Constipation related to decreased bowel motility and decreased fluid intake
- D. Chronic pain related to appendicitis
Correct Answer: B
Rationale: The correct answer is B: Risk for infection related to possible rupture of the appendix. This is the priority nursing diagnosis because appendicitis can lead to a life-threatening condition if the appendix ruptures. The nurse needs to monitor for signs of worsening infection such as fever and increased pain.
A: Imbalanced nutrition is not the priority as it is secondary to the risk of infection.
C: Constipation is not the priority as it is not directly related to the life-threatening complication of appendicitis.
D: Chronic pain is also not the priority as the risk of infection and potential rupture take precedence in the care of the patient.
The healthcare provider is providing care to a client with a tracheostomy. Which action should the healthcare provider take to prevent tracheostomy complications?
- A. Use sterile technique when performing tracheostomy care.
- B. Suction the tracheostomy tube every hour.
- C. Keep the tracheostomy tube cuff inflated at all times.
- D. Change the tracheostomy ties daily.
Correct Answer: A
Rationale: The correct answer is A: Use sterile technique when performing tracheostomy care. This is crucial to prevent infections that can lead to complications. Sterile technique helps minimize the risk of introducing harmful pathogens into the tracheostomy site. Using clean rather than sterile technique can increase the client's risk of infection.
Choice B is incorrect because suctioning the tracheostomy tube every hour can lead to mucosal damage and increase the risk of infection. Choice C is incorrect because keeping the tracheostomy tube cuff inflated at all times can cause pressure ulcers and damage the trachea. Choice D is incorrect because changing the tracheostomy ties daily is unnecessary and can increase the risk of dislodging the tracheostomy tube, leading to complications.
A client with acute pancreatitis is admitted to the hospital. What is the priority nursing intervention for this client?
- A. Administering oral pancreatic enzymes
- B. Encouraging a high-protein diet
- C. Maintaining NPO status and administering IV fluids
- D. Providing a low-fat diet
Correct Answer: C
Rationale: The priority nursing intervention for a client with acute pancreatitis is maintaining NPO status and administering IV fluids (Choice C). This is because pancreatitis causes inflammation of the pancreas, leading to digestive enzyme release and auto-digestion of pancreatic tissue. By keeping the client NPO, it helps rest the pancreas and decrease enzyme secretion, which can reduce further damage. Administering IV fluids is crucial to maintain hydration and replace lost fluids due to vomiting or decreased oral intake. Choices A, B, and D are incorrect as they focus on dietary interventions such as oral pancreatic enzymes, high-protein, or low-fat diet, which are not appropriate as initial priorities in the acute phase of pancreatitis.
A healthcare professional is preparing to administer digoxin 0.25 mg PO daily. The amount available is digoxin 0.125 mg tablets. How many tablets should the healthcare professional administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: B
Rationale: The correct answer is B: 2 tablets. To administer 0.25 mg of digoxin daily using 0.125 mg tablets, the healthcare professional should give 2 tablets. Each tablet is 0.125 mg, so 2 tablets will equal 0.25 mg, which is the required dose. The other choices are incorrect because administering 1 tablet would only provide 0.125 mg (half the required dose), administering 3 tablets would provide 0.375 mg (exceeding the required dose), and administering 4 tablets would provide 0.5 mg (double the required dose). Thus, the correct answer is to administer 2 tablets to achieve the prescribed 0.25 mg dose.