Nokea
A nurse is caring for a client with increased intracranial pressure caused by cerebral edema. The physician has prescribed mannitol. After administering the drug, the nurse should do which of the following?
- A. Monitor blood pressure every 4 hours
- B. Check response of pupils to light
- C. Monitor client for joint pain
- D. Monitor serum uric acid concentrations
Correct Answer: B
Rationale: When caring for a client who has been given mannitol for intracranial pressure, the nurse should perform neurologic assessments such as response of the pupils to light, level of consciousness, or response to a painful stimulus.
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A client is prescribed a diuretic that is to be taken twice a day. When instructing the client about the schedule for administration, the nurse would suggest that the client take the drug at which times?
- A. In the early morning and at bedtime
- B. After lunch and dinner
- C. At breakfast and midafternoon
- D. Midmorning and before dinner
Correct Answer: C
Rationale: Twice-a-day dosing should be administered early in the morning (e.g., 7 a.m.) and early afternoon (e.g., 2 p.m.) to prevent the drug from interfering with the client's sleep.
A nurse is assessing a client after administering a diuretic. Which of the following would lead the nurse to suspect that the client is experiencing a fluid and electrolyte imbalance? Select all that apply.
- A. Dry mouth
- B. Diaphoresis
- C. Muscle cramps
- D. Hypertension
- E. Tachycardia
Correct Answer: A,C,E
Rationale: Warning signs of a fluid and electrolyte imbalance include dry mouth, thirst, lethargy, weakness, drowsiness, restlessness, muscle pain or cramps, confusion, GI disturbances, hypotension, oliguria, tachycardia, and seizures.
A nurse is caring for a client with edema due to congestive heart failure (CHF). The primary health care provider has prescribed indapamide. The client is also receiving digoxin. Which intervention would be most appropriate for the nurse to implement?
- A. Encourage oral fluids at frequent intervals during waking hours
- B. Encourage the client to eat or drink between meals and in the evening
- C. Frequently monitor the client's pulse rate and rhythm
- D. Closely monitor the client for signs of hyperkalemia
Correct Answer: C
Rationale: Clients receiving a diuretic, particularly a loop or thiazide diuretic such as indapamide, and a digitalis glycoside concurrently require frequent monitoring of the pulse rate and rhythm.
A nurse is preparing to administer spironolactone to a client. When reviewing the client's medical record, the nurse would be alert for the development of hyperkalemia if the client was also receiving which of the following?
- A. Lisinopril (Prinivil)
- B. Metoprolol (Lopressor)
- C. Terazosin (Hytrin)
- D. Diltiazem (Cardizem)
Correct Answer: A
Rationale: Spironolactone when given with ACE inhibitors (lisinopril) can lead to hyperkalemia.
A nurse is reviewing the laboratory test results of a client who is receiving diuretic therapy. The nurse determines that the client is at risk for electrolyte imbalance based on which results? Select all that apply.
- A. Potassium 4.5 mEq/L
- B. Sodium 139 mEq/L
- C. Magnesium 2.0 mEq/L
- D. Sodium 124 mEq/L
- E. Potassium 2.9 mEq/L
Correct Answer: D,E
Rationale: Sodium levels below 132 mEq/L, such as 124 mEq/L, or above 145 mEq/L would indicate an imbalance. Potassium imbalances would occur with levels below 3.0 mEq/L, such as 2.9 mEq/L.