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The nurse is caring for a client with a history of heart failure who is receiving spironolactone (Aldactone) 25 mg PO daily. Which of the following laboratory results should the nurse report immediately?
- A. Potassium 5.8 mEq/L.
- B. Sodium 138 mEq/L.
- C. Creatinine 1.2 mg/dL.
- D. Calcium 9.0 mg/dL.
Correct Answer: A
Rationale: Hyperkalemia (5.8 mEq/L) is a serious spironolactone side effect, risking arrhythmias. Options B, C, and D are normal.
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The nurse is teaching a client with a new diagnosis of osteoporosis about alendronate (Fosamax). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication first thing in the morning.
- B. I should remain upright for 30 minutes after taking it.
- C. I should take it with a full glass of water.
- D. I should take it with my calcium supplement.
Correct Answer: D
Rationale: Taking alendronate with a calcium supplement is incorrect, as it reduces absorption; they should be taken at different times. Options A, B, and C are correct: morning dosing, remaining upright, and taking with water minimize esophageal irritation and maximize absorption.
A 16-year-old young woman is brought by her parents to the outpatient clinic for treatment of pelvic inflammatory disease (PID). While the nurse obtains a history, the client says bitterly, 'My parents are mean and don't really care about me.' Which of the following responses by the nurse is BEST?
- A. You feel your parents don't care about you?
- B. Your parents brought you to the clinic, didn't they?
- C. I am sure that your parents have your best interests at heart.
- D. Did you have a disagreement with your parents?
Correct Answer: A
Rationale: Reflecting the client’s feelings validates her emotions, encouraging therapeutic communication. Options B, C, and D are nontherapeutic, dismissing or challenging her statement.
The nurse is caring for a client with a history of heart failure who is receiving lisinopril (Prinivil) 10 mg PO daily. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Potassium 5.5 mEq/L.
- B. Sodium 138 mEq/L.
- C. Creatinine 1.2 mg/dL.
- D. Calcium 9.0 mg/dL.
Correct Answer: A
Rationale: Hyperkalemia (potassium 5.5 mEq/L) is a serious complication of lisinopril, an ACE inhibitor, risking arrhythmias in heart failure. Options B, C, and D are normal: sodium 138 mEq/L, creatinine 1.2 mg/dL, and calcium 9.0 mg/dL do not indicate complications.
The nurse has just received report on a group of clients and plans to delegate care of several of the clients to a practical nurse (PN). The first thing the RN should do before the delegation of care is
- A. Provide a time-frame for the completion of the client care
- B. Assure the PN that the RN will be available for assistance
- C. Ask about prior experience with similar clients
- D. Review the specific procedures unique to the assignment
Correct Answer: C
Rationale: The first step in delegation is to determine the qualifications of the person to whom one is delegating. By asking about the PN’s prior experience with similar clients/tasks, the RN can determine whether the PN has the requisite experience to care for the assigned clients.
An adult has the following blood gasses: pH=7.52, pCO2=50, HCO3=35, and pO2=90. What is most likely to be in the client's history of presenting signs and symptoms?
- A. Persistent diarrhea
- B. Frequent vomiting
- C. Anxiety attack
- D. Emphysema
Correct Answer: B
Rationale: High pH and HCO3 indicate metabolic alkalosis, commonly caused by frequent vomiting, losing gastric acid.