Nokea
While assisting in caring for a pregnant client receiving intravenous magnesium sulfate for preeclampsia management, a nurse notes the client's absent deep tendon reflexes. What determination should the nurse make based on this data?
- A. The magnesium sulfate is effective.
- B. The infusion rate needs to be increased.
- C. The client is experiencing cerebral edema.
- D. The client is experiencing magnesium toxicity.
Correct Answer: D
Rationale: When a pregnant client receiving intravenous magnesium sulfate for preeclampsia management exhibits absent deep tendon reflexes, this indicates magnesium toxicity. Magnesium toxicity can occur as a complication of magnesium sulfate therapy, leading to suppressed reflexes. It is crucial for the nurse to recognize this sign promptly and report it to prevent further complications or harm to the client.
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The client has reinforced instructions for taking cholestyramine (Questran). Which statement indicates a need for further instructions?
- A. I will continue taking vitamin supplements.
- B. This medication will help lower my cholesterol.
- C. This medication should only be taken with water.
- D. A high-fiber diet is important while taking this medication.
Correct Answer: C
Rationale: The correct answer is C because cholestyramine should not only be taken with water. Flavored products or fruit juices can improve the taste. Choices A, B, and D are all correct statements. It is important for the client to continue taking vitamin supplements, understand that cholestyramine helps lower cholesterol, and maintain a high-fiber diet while taking this medication to enhance its effectiveness.
A client with hypertension is prescribed lisinopril (Zestril). Which instruction should the nurse include in the teaching plan?
- A. Avoid foods high in potassium.
- B. Avoid taking the medication with grapefruit juice.
- C. Monitor blood pressure regularly.
- D. Report any swelling of the lips or face.
Correct Answer: D
Rationale: The correct instruction for the nurse to include in the teaching plan is to 'Report any swelling of the lips or face.' Lisinopril (Zestril) can cause angioedema, which is swelling of the lips or face. This is a serious side effect that should be reported immediately. Clients do not need to avoid potassium-rich foods unless instructed by their healthcare provider, should avoid taking the medication with grapefruit juice, and should monitor their blood pressure regularly, not just weekly.
A client who is taking hydrochlorothiazide (HydroDIURIL, HCTZ) has been started on triamterene (Dyrenium) as well. The client asks the nurse why both medications are required. The nurse formulates a response, based on the understanding that:
- A. Both are weak potassium-losing diuretics.
- B. The combination of these medications prevents renal toxicity.
- C. Hydrochlorothiazide is less expensive, so using a combination of diuretics is cost-effective.
- D. Triamterene is a potassium-sparing diuretic, whereas hydrochlorothiazide is a potassium-losing diuretic.
Correct Answer: D
Rationale: The combination of triamterene and hydrochlorothiazide is used because triamterene is a potassium-sparing diuretic, which helps retain potassium, while hydrochlorothiazide is a potassium-losing diuretic, which promotes potassium excretion. This combination helps balance potassium levels in the body, preventing imbalances that can occur when using potassium-losing diuretics alone.
A home health care nurse is visiting a client with elevated triglyceride levels and a serum cholesterol level of 398 mg/dL. The client is taking cholestyramine (Questran). Which of the following statements, if made by the client, indicates the need for further education?
- A. Constipation and bloating might be a problem.
- B. I'll continue to watch my diet and reduce my fats.
- C. Walking a mile each day will help the whole process.
- D. I'll continue my nicotinic acid from the health food store.
Correct Answer: D
Rationale: Nicotinic acid, even an over-the-counter form, should be avoided because it may lead to liver abnormalities. All lipid-lowering medications also can cause liver abnormalities, so a combination of nicotinic acid and cholestyramine resin is to be avoided. Constipation and bloating are the two most common side effects. Walking and the reduction of fats in the diet are therapeutic measures to reduce cholesterol and triglyceride levels.
A client with hypertension is prescribed losartan (Cozaar). Which instruction should the nurse include in the teaching plan?
- A. Avoid foods high in potassium.
- B. Take the medication with grapefruit juice.
- C. Monitor blood pressure weekly.
- D. Report any swelling of the lips or face.
Correct Answer: D
Rationale: The correct instruction for a client prescribed losartan (Cozaar) is to report any swelling of the lips or face. Losartan can cause angioedema, which is a serious side effect that requires immediate medical attention. Clients do not need to avoid potassium-rich foods unless specifically instructed by their healthcare provider. Taking the medication with grapefruit juice is not recommended as it can interact with certain medications. Additionally, monitoring blood pressure regularly is important, but it should not be limited to a weekly basis; blood pressure should be monitored as per the healthcare provider's recommendation.