Nokea
The nurse is caring for four hypertensive clients. Which drug/laboratory value combination should the nurse report immediately to the health care provider?
- A. Furosemide (Lasix)/potassium 2.1 mEq/L
- B. Hydrochlorothiazide/potassium 3.5 mEq/L
- C. Spironolactone (Aldactone)/potassium 5.1 mEq/L
- D. Losartan/sodium 135 mEq/L
Correct Answer: A
Rationale: Lasix is a loop diuretic and can cause hypokalemia. A potassium level of 2.1 mEq/L is critically low and should be reported immediately. A potassium level of 5.1 mEq/L is on the high side but not as critical. The other laboratory values are within normal ranges.
You may also like to solve these questions
A nurse is assessing a client with peripheral artery disease (PAD). The client states walking five blocks is possible without pain. What question asked next by the nurse will give the best information?
- A. Could you walk further than that a few months ago?
- B. Do you walk mostly uphill, downhill, or on flat surfaces?
- C. Have you ever considered swimming instead of walking?
- D. How much pain medication do you take each day?
Correct Answer: A
Rationale: As PAD progresses, it takes less oxygen demand to cause pain. Needing to cut down on activity to be pain-free indicates the client's disease is worsening. The other questions are useful but not as critical.
A client had a percutaneous transluminal coronary angioplasty for peripheral arterial disease. What assessment finding indicates a priority outcome for this client has been met?
- A. Pain rated as 2/10 after medication
- B. Distal pulse on affected extremity 2+/4
- C. Client remains on bedrest as directed
- D. Verifies understanding of procedure
Correct Answer: B
Rationale: Assessing circulation distal to the puncture site is a critical nursing action. A pulse of 2+/4 indicates good perfusion, meeting a priority outcome. The other options are important but secondary to circulation.
A student nurse asks what essential hypertension is. What response by the registered nurse is best?
- A. It is caused by another disease
- B. It means it must be treated immediately
- C. It has no specific cause
- D. It refers to severe and life-threatening hypertension
Correct Answer: C
Rationale: Essential hypertension is the most common type of hypertension and has no specific cause such as an underlying disease process. Hypertension caused by another disease is secondary hypertension. Severe, life-threatening hypertension is malignant hypertension.
The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates the client is managing this condition well with diet?
- A. A 4-ounce steak, French fries, iceberg lettuce
- B. Baked chicken breast, broccoli, tomatoes
- C. Fried catfish, cornbread, peas
- D. Spaghetti with meat sauce, garlic bread
Correct Answer: B
Rationale: The diet recommended for this client would be low in saturated fats and red meat, high in vegetables and whole grains (fiber), low in salt, and low in trans fat. The best choice is baked chicken with broccoli and tomatoes. The French fries have too much fat and the iceberg lettuce has little fiber. The catfish is fried. The spaghetti dinner has too much red meat and no vegetables.
A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Ambulate the client
- B. Apply a warm moist pack
- C. Massage the client's leg
- D. Provide an ice pack
Correct Answer: B
Rationale: Warm moist packs can help with the pain of a DVT. Ambulation is not a comfort measure. Massaging the client's legs is contraindicated to prevent complications such as pulmonary embolism. Ice packs are not recommended for DVT.