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Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective?
- A. I will try to drink at least 8 glasses of water every day.
- B. I will use a salt substitute to decrease my sodium intake.
- C. I will increase my intake of potassium-containing foods.
- D. I will drink apple juice instead of orange juice for breakfast.
Correct Answer: D
Rationale: The correct answer is D. Spironolactone is a potassium-sparing diuretic, so patients should choose low-potassium foods. Apple juice is a better choice than orange juice in this case as it is lower in potassium. Option A is incorrect because increasing fluid intake excessively is not necessary. Option B is incorrect as salt substitutes are high in potassium, which should be avoided. Option C is incorrect because patients on spironolactone should avoid increasing their potassium intake.
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When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient's food tray?
- A. Grape juice
- B. Milk carton
- C. Mixed green salad
- D. Fried chicken breast
Correct Answer: B
Rationale: The correct answer is B: Milk carton. Foods high in phosphate, like milk and other dairy products, are restricted on low-phosphate diets to manage renal failure. Green, leafy vegetables, high-fat foods, and fruits/juices are not high in phosphate and are not restricted. Therefore, grape juice, mixed green salad, and fried chicken breast do not need to be removed from the patient's food tray.
A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse?
- A. Arterial blood pH is 7.32.
- B. Serum calcium is 18 mg/dL.
- C. Serum potassium is 5.1 mEq/L
- D. Arterial oxygen saturation is 91%.
Correct Answer: B
Rationale: The correct answer is B. A serum calcium level of 18 mg/dL is significantly elevated, posing a high risk for cardiac dysrhythmias. Immediate action is required to initiate cardiac monitoring and notify the healthcare provider. While the abnormalities in arterial blood pH, serum potassium, and arterial oxygen saturation also need attention, they are not as immediately life-threatening as the critically high serum calcium level. Therefore, addressing the serum calcium level takes precedence in this scenario.
The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake?
- A. Increase fluids if your mouth feels dry.
- B. More fluids are needed if you feel thirsty.
- C. Drink more fluids in the late evening hours.
- D. If you feel lethargic or confused, you need more to drink.
Correct Answer: A
Rationale: The correct answer is A. An alert, older patient can self-assess for signs of dehydration like dry mouth. This instruction is appropriate as it encourages the patient to respond to early signs of dehydration. Choice B is incorrect because the thirst mechanism decreases with age and feeling thirsty may not accurately indicate the need for fluids. Choice C is incorrect as many older patients prefer to limit evening fluid intake to enhance sleep quality. Choice D is incorrect because an older adult who is lethargic or confused may not be able to accurately assess their need for fluids.
A patient comes to the clinic complaining of frequent, watery stools for the last 2 days. Which action should the nurse take first?
- A. Obtain the baseline weight
- B. Check the patient's blood pressure
- C. Draw blood for serum electrolyte levels
- D. Ask about any extremity numbness or tingling
Correct Answer: B
Rationale: The correct answer is to check the patient's blood pressure. Given the patient's symptoms of frequent, watery stools, there is a concern for fluid volume deficit. Assessing the blood pressure helps determine the patient's perfusion status, which is crucial in managing fluid volume deficits. While obtaining baseline weight, drawing blood for serum electrolyte levels, and asking about extremity numbness or tingling are important assessments, checking the blood pressure takes precedence as it provides immediate information on the patient's circulatory status.
A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse?
- A. The patient's radial pulse is 105 beats/minute.
- B. There is sediment and blood in the patient's urine.
- C. The blood pressure increases from 120/80 to 142/94.
- D. There are crackles audible throughout both lung fields.
Correct Answer: D
Rationale: Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure and the presence of sediment and blood in the urine should also be reported, but they are not as immediately dangerous as the presence of fluid in the alveoli, which compromises gas exchange and can lead to respiratory failure.