A nurse is administering spironolactone at 0800 to a client who has heart failure.
The nurse should monitor the client for which of the following adverse effects?

Hypernatremia.

Hyperkalemia.

Hypophosphatemia.

Hypocalcemia.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Hypernatremia (high sodium levels) is not a common side effect of spironolactone. Spironolactone is a potassium-sparing diuretic and does not typically affect sodium levels.

Choice B rationale:

Hyperkalemia (high potassium levels) is a potential adverse effect of spironolactone. As a potassium-sparing diuretic, spironolactone can cause an increase in serum potassium levels.

Choice C rationale:

Hypophosphatemia (low phosphate levels) is not typically associated with spironolactone use.

Choice D rationale:

Hypocalcemia (low calcium levels) is also not a common side effect of spironolactone.

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Correct Answer is A

Explanation

Choice A rationale:

A respiratory rate of 10/min is lower than the normal range (12-20 breaths per minute for adults), indicating respiratory depression, which is a serious side effect of morphine and should be reported immediately.

Choice B rationale:

Facial flushing is a common side effect of morphine due to histamine release but it’s not life-threatening.

Choice C rationale:

Constipation is a common side effect of morphine and can be managed with laxatives and diet.

Choice D rationale:

Blood pressure 88/56 mm Hg is lower than the normal range (90/60mmHg to 120/80mmHg), indicating hypotension, which can be a side effect of morphine but it’s not as immediately life-threatening as respiratory depression.

A. Tell the client they can have another dose of ketorolac in 3 hr. B. Administer oxycodone 5 mg orally. C. Give acetaminophen 650 mg rectally. D. Document that the client is exhibiting drug-seeking behaviors.

Correct Answer is B

Explanation

Choice A rationale:

Ketorolac is a non-steroidal anti-inflammatory drug (NSAID) used for pain relief after surgery. However, it’s not typically administered every 3 hours. Overuse can lead to serious side effects.

Choice B rationale:

If the client’s pain level remains high after receiving ketorolac, administering an opioid medication like oxycodone may be appropriate.

Choice C rationale:

While acetaminophen can be used for pain relief, rectal administration is not typically the first choice for postoperative pain management.

Choice D rationale:

It’s inappropriate to label a patient as exhibiting drug-seeking behaviors simply because their reported pain level remains high after medication. Pain is subjective and should be addressed appropriately.

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A nurse is administering spironolactone at 0800 to a client who has heart failure.The nurse should monitor the client for which of the following adverse effects?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who is receiving morphine via a continuous epidural infusion.Which of the following findings should the nurse report to the provider immediately?

Correct Answer is A

Explanation

A nurse is caring for a client who is postoperative following arthroscopy and reports a pain level of 6 on a scale of 0 to 10 after receiving ketorolac 1 hr ago.Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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A nurse is administering spironolactone at 0800 to a client who has heart failure.
The nurse should monitor the client for which of the following adverse effects?