Nokea
The client is on spironolactone (Aldactone) and has a potassium level of 5.9 mEq/L. What is the nurse's priority action?
- A. Hold the spironolactone and notify the healthcare provider.
- B. Administer potassium supplements.
- C. Continue the spironolactone as ordered.
- D. Increase the dose of spironolactone.
Correct Answer: A
Rationale: The correct answer is A: Hold the spironolactone and notify the healthcare provider. Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia. With a potassium level of 5.9 mEq/L, the client is at risk for serious complications like cardiac arrhythmias. The priority action is to stop the medication to prevent further elevation of potassium levels and inform the healthcare provider for further management. Administering potassium supplements (B) would worsen the hyperkalemia. Continuing spironolactone (C) or increasing the dose (D) would be inappropriate and potentially harmful in this situation.
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The client is on spironolactone (Aldactone). What is the most important dietary instruction?
- A. Avoid foods high in potassium.
- B. Increase intake of foods high in potassium.
- C. Avoid foods high in sodium.
- D. Increase intake of foods high in sodium.
Correct Answer: A
Rationale: The correct answer is A: Avoid foods high in potassium. Spironolactone is a potassium-sparing diuretic that can increase potassium levels in the body. Consuming foods high in potassium while on spironolactone can lead to hyperkalemia, which can be dangerous. By avoiding foods high in potassium, the client can help maintain a safe potassium level.
Summary:
- Choice B (Increase intake of foods high in potassium) is incorrect because it can lead to hyperkalemia when combined with spironolactone.
- Choice C (Avoid foods high in sodium) is unrelated to spironolactone's mechanism of action.
- Choice D (Increase intake of foods high in sodium) is incorrect as it is not relevant to the dietary instruction needed for a client on spironolactone.
What structure separates the left and right sides of the heart?
- A. Interventricular septum
- B. Endocardium
- C. Epicardium
- D. Pericardium
Correct Answer: A
Rationale: The correct answer is A: Interventricular septum. This structure separates the left and right sides of the heart, forming a barrier between the two ventricles. It ensures that oxygenated and deoxygenated blood do not mix within the heart chambers. The endocardium (B) is the inner layer of the heart's chambers, the epicardium (C) is the outer layer of the heart, and the pericardium (D) is the sac surrounding the heart. These structures do not specifically separate the left and right sides of the heart.
A long-term-care resident with venous stasis ulcers is treated with Unna's boot. Which of the nursing activities included in the resident's care is best for you to delegate to a nursing assistant?
- A. Monitor capillary perfusion once every 8 hours.
- B. Teach family members the signs of infection.
- C. Evaluate foot sensation and movement each shift.
- D. Assist patient with cleaning around Unna's boot.
Correct Answer: D
Rationale: Cleaning around the boot is a simple task suitable for a nursing assistant.
What is a condition where the blood pressure in the arteries is consistently too high, increasing the risk of heart disease and stroke?
- A. Hypertension
- B. Hypotension
- C. Diabetes
- D. Hyperlipidemia
Correct Answer: A
Rationale: Step-by-step rationale:
1. Hypertension is defined as consistently high blood pressure, a major risk factor for heart disease and stroke.
2. Hypotension is low blood pressure, not associated with increased risk of heart disease or stroke.
3. Diabetes is a metabolic disorder, not directly related to blood pressure.
4. Hyperlipidemia is high levels of fats in the blood, which can contribute to heart disease but not specifically related to high blood pressure.
Summary:
Hypertension is the correct answer because it specifically refers to high blood pressure, a significant risk factor for heart disease and stroke. Hypotension, diabetes, and hyperlipidemia are incorrect as they do not directly cause consistently high blood pressure.
What is a condition where the heart muscle becomes abnormally enlarged, thickened, or stiffened, often leading to heart failure?
- A. Cardiomyopathy
- B. Pericarditis
- C. Aortic stenosis
- D. Mitral valve prolapse
Correct Answer: A
Rationale: The correct answer is A: Cardiomyopathy. Cardiomyopathy is a condition characterized by abnormal enlargement, thickening, or stiffening of the heart muscle, which can lead to heart failure. This condition directly affects the heart muscle itself, causing it to function improperly. Pericarditis (B) is inflammation of the pericardium, the outer lining of the heart, not the heart muscle. Aortic stenosis (C) and Mitral valve prolapse (D) involve issues with heart valves, not the heart muscle itself. Therefore, A is the correct choice as it directly addresses the abnormal changes in the heart muscle leading to heart failure.