Nokea
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 client statements would be of GREATest concern to the nurse?
- A. I feel tired in the afternoon.
- B. I have a dry mouth.
- C. I have muscle cramps.
- D. I take my medication with food.
Correct Answer: C
Rationale: Muscle cramps suggest hyperkalemia, a serious side effect of spironolactone, a potassium-sparing diuretic, requiring immediate evaluation to prevent arrhythmias. Options A, B, and D are less concerning: fatigue and dry mouth are nonspecific, and taking with food is acceptable.
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A low-purine diet is ordered for a client who has uric acid kidney stones. Which foods should the client avoid? Select all that apply.
- A. Eggs
- B. Chicken
- C. Liver
- D. Oats
- E. Lentils
- F. Lobster
Correct Answer: C,F
Rationale: Liver and lobster are high-purine foods, increasing uric acid production, which worsens uric acid kidney stones. Eggs, chicken, oats, and lentils are lower in purines and safer.
An obstetrical client elects to have epidural anesthesia with Marcaine. After the epidural anesthesia is given, the nurse should monitor the client for signs of:
- A. Seizure activity
- B. Respiratory depression
- C. Postural hypotension
- D. Hematuria
Correct Answer: C
Rationale: Marcaine (bupivacaine) can cause vasodilation, leading to postural hypotension. Seizures, respiratory depression, and hematuria are less common.
A polydrug user has been in recovery for 8 months. The client has began skipping breakfast and not eating regular dinners. The client has also started frequenting bars to 'see old buddies.' The nurse understands that the client's behaviors are warning signs to indicate that the client may be
- A. Headed for relapse
- B. Feeling hopeless
- C. Approaching recovery
- D. In need of increased socialization
Correct Answer: A
Rationale: Headed for relapse. These behaviors suggest a return to risky environments and habits, indicating potential relapse.
The nurse has just returned to the desk and has four phone messages to return.
- A. Which phone message should the nurse return first?
- B. A woman in her first trimester of pregnancy complaining of heartburn.
- C. A man complaining of heartburn that radiates to his jaw.
- D. A woman complaining of hot flashes and difficulty sleeping.
- E. A boy complaining of knee pain after playing basketball.
Correct Answer: B
Rationale: Heartburn radiating to the jaw in a man indicates possible chest pain, which could be a symptom of a myocardial infarction, a life-threatening condition requiring immediate medical attention. The other conditions (pregnancy-related heartburn, menopausal symptoms, and knee pain) are less urgent and can be addressed after ruling out a cardiac emergency.
The nurse is caring for a client on complete bed rest. Which action by the nurse is most important in preventing the formation of deep vein thrombosis?
- A. Elevate the foot of the bed
- B. Apply knee high support stockings
- C. Encourage passive exercises
- D. Prevent pressure at back of knees
Correct Answer: D
Rationale: Preventing popliteal pressure will prevent venous stasis and possibly deep vein thrombosis.