Nokea
The client on spironolactone (Aldactone) has a potassium level of 5.8 mEq/L. What is the nurse's priority action?
- A. Hold the spironolactone and notify the healthcare provider.
- B. Administer a potassium supplement.
- 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. The priority action is to stop the medication and inform the healthcare provider because a potassium level of 5.8 mEq/L is above the normal range (3.5-5.0 mEq/L), indicating hyperkalemia. Spironolactone is a potassium-sparing diuretic that can further increase potassium levels. Continuing the medication or administering a potassium supplement would exacerbate the issue. Increasing the dose of spironolactone would be unsafe and could lead to severe complications. Therefore, holding the medication and seeking guidance from the healthcare provider is crucial in managing the client's elevated potassium level.
You may also like to solve these questions
If Mr. Lane, with essential hypertension, complains of dizziness when changing position, your evaluation would be that Mr. Lane
- A. is probably not taking his medications properly
- B. should be instructed in preventing hypotensive reactions
- C. is responding as expected to the prescribed medications
- D. should be totally reevaluated
Correct Answer: B
Rationale: Dizziness may indicate postural hypotension, requiring preventive education.
What is a condition where the arteries that supply blood to the heart muscle become hardened and narrowed due to the buildup of plaque?
- A. Atherosclerosis
- B. Aneurysm
- C. Arrhythmia
- D. Peripheral artery disease
Correct Answer: A
Rationale: The correct answer is A: Atherosclerosis. Atherosclerosis is the condition where arteries supplying blood to the heart become hardened and narrowed due to plaque buildup, leading to decreased blood flow and potential heart issues. Aneurysm (B) is the weakening and bulging of an artery wall, not related to plaque buildup. Arrhythmia (C) is an irregular heartbeat, not directly related to arterial blockages. Peripheral artery disease (D) involves narrowing of arteries in the limbs, not specifically related to the heart. Thus, Atherosclerosis is the most fitting choice for the given condition.
When administering enoxaparin (Lovenox) to a client, what is the most important lab value to monitor?
- A. Platelet count
- B. aPTT
- C. Hemoglobin
- D. INR
Correct Answer: A
Rationale: The correct answer is A: Platelet count. When administering enoxaparin, the most important lab value to monitor is the platelet count because enoxaparin can cause thrombocytopenia, a potentially serious adverse effect. Monitoring platelet count helps to detect and prevent this complication.
Summary of other choices:
B: aPTT - Enoxaparin does not directly affect aPTT, so monitoring this value is not as critical as platelet count.
C: Hemoglobin - While monitoring hemoglobin may be important for some conditions, it is not the most crucial lab value to monitor when administering enoxaparin.
D: INR - Enoxaparin does not affect the INR, so monitoring this value is not necessary when administering this medication.
The laboratory tests for four patients show the following results. Which patient should the nurse teach first about preventing CAD because the patient is at the greatest risk for CAD even without other risk factors?
- A. Total cholesterol: 152 mg/dL, triglycerides: 148 mg/dL, LDL: 148 mg/dL, HDL: 52 mg/dL
- B. Total cholesterol: 160 mg/dL, triglycerides: 102 mg/dL, LDL: 138 mg/dL, HDL: 56 mg/dL
- C. Total cholesterol: 200 mg/dL, triglycerides: 150 mg/dL, LDL: 160 mg/dL, HDL: 48 mg/dL
- D. Total cholesterol: 250 mg/dL, triglycerides: 164 mg/dL, LDL: 172 mg/dL, HDL: 32 mg/dL
Correct Answer: D
Rationale: Low HDL and high LDL increase CAD risk.
What is a condition where the right side of the heart fails due to increased pressure in the pulmonary arteries, often caused by chronic lung disease?
- A. Cor pulmonale
- B. Heart failure
- C. Pulmonary embolism
- D. Myocarditis
Correct Answer: A
Rationale: The correct answer is A: Cor pulmonale. Cor pulmonale is right-sided heart failure due to increased pressure in the pulmonary arteries, typically caused by chronic lung disease. This leads to the right side of the heart working harder to pump blood through the lungs, resulting in eventual failure. Pulmonary embolism (C) is a sudden blockage in the pulmonary artery, not a chronic condition. Heart failure (B) is a general term for when the heart is unable to pump blood effectively, not specific to the right side. Myocarditis (D) is inflammation of the heart muscle, not directly related to pulmonary hypertension.