Nokea
A nurse administering potassium to a client should monitor the client closely for signs of hyperkalemia if the client is concomitantly taking which of the following medications? Select all that apply.
- A. Lisinopril (Prinivil)
- B. Metoprolol (Lopressor)
- C. Spironolactone (Aldactone)
- D. Furosemide (Lasix)
- E. Hydrochlorothiazide
Correct Answer: A,C
Rationale: A nurse administering potassium to a client should monitor the client closely for signs of hyperkalemia if the client is concomitantly taking the following medications: ACE inhibitors (lisinopril) and potassium-sparing diuretics, such as spironolactone.
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A nurse is administering IV fluid and electrolyte therapy to a client. The nurse reviews the client's laboratory test results. Which result would the nurse immediately report to the primary health care provider?
- A. Calcium 4.7 mEq/L
- B. Magnesium 2.0 mEq/L
- C. Potassium 2.1 mEq/L
- D. Sodium 140 mEq/L
Correct Answer: C
Rationale: The nurse would report a potassium level of 2.1 mEq/L because this indicates hypokalemia. A calcium level of 4.7 mEq/L, magnesium level of 2.0 mEq/L, and sodium level of 140 mEq/L are within normal ranges.
A nurse is caring for a client who is receiving ammonium chloride. The nurse would be alert for the development of which of the following as a possible adverse reaction?
- A. Depressed reflexes
- B. Muscle weakness
- C. Circulatory collapse
- D. Metabolic acidosis
Correct Answer: D
Rationale: The nurse should monitor the client's condition for metabolic acidosis as an adverse reaction to ammonium chloride.
A nurse is caring for a client who has been prescribed potassium. From the client's health history, the nurse understands that the client has also been taking salt substitutes. Which of the following conditions should the nurse monitor for in this client, occurring due to the interaction of the salt substitutes with potassium?
- A. Severe hemolytic reactions
- B. Elevated serum potassium levels
- C. Acute dehydration
- D. Severe hyperkalemia
Correct Answer: D
Rationale: The nurse should monitor the client's condition for signs and symptoms of severe hyperkalemia, which occurs due to the interaction of potassium with salt substitutes.
A nurse is assigned to care for a client who is receiving IV fat emulsions. The nurse reviews the client's history and identifies the need to administer the fat emulsion cautiously based on which of the following?
- A. The client has a pulmonary disorder.
- B. The client is allergic to eggs.
- C. The client has acute pancreatitis
- D. The client has a vitamin deficiency.
Correct Answer: A
Rationale: When caring for a client who is to receive IV fat emulsions, the nurse should know that IV fat emulsions are to be used cautiously if the client has a pulmonary disorder, severe liver impairment, anemia, and blood coagulation disorders.
A nurse is preparing to initiate IV access for a client who is prescribed IV fluid therapy. After selecting the site, which of the following would the nurse do next?
- A. Place a tourniquet above the selected site.
- B. Cleanse the site according to facility policy.
- C. Insert the needle while pulling the skin taut.
- D. Check for blood flow.
Correct Answer: A
Rationale: When a site has been selected for venipuncture, the nurse places a tourniquet above the selected vein, then cleanses the site according to facility policy.