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 D

Explanation

Choice A rationale:

Two loose stools in the past 24 hours could be a symptom of Clostridioides difficile infection, but it’s not necessarily a priority finding. The infection can cause diarrhea, but it’s not life-threatening.

Choice B rationale:

A WBC count of 11,000/mm³ is slightly elevated, indicating a possible infection. However, it’s not necessarily a priority finding as it’s not significantly high.

Choice C rationale:

A heart rate of 104/min is slightly elevated, indicating possible stress or anxiety. However, it’s not necessarily a priority finding as it’s not significantly high.

Choice D rationale:

Creatinine level of 3.1 mg/dL is significantly high, indicating possible kidney damage, which can be a side effect of vancomycin treatment. This should be reported to the provider immediately.

A. The nurse asks the client to demonstrate dose delivery. B. The nurse administers a PCA dose for the client. C. The nurse reassures the client that the PCA device will not cause an overdose. D. The nurse monitors the client for oversedation.

Correct Answer is B

Explanation

Choice A rationale:

Asking the client to demonstrate dose delivery can be part of patient education and helps ensure that the client understands how to use the PCA device. This action does not require intervention.

Choice B rationale:

The nurse administering a PCA dose for the client requires intervention. PCA stands for “Patient-Controlled Analgesia,” meaning that only the patient should administer doses to themselves. This prevents overdosing and ensures that pain medication is administered according to the patient’s needs.

Choice C rationale:

Reassuring the client that the PCA device will not cause an overdose is appropriate because PCA devices are designed with safety measures to prevent overdosing.

Choice D rationale:

Monitoring for oversedation is an important part of care for a client using a PCA device. This action does not require intervention.

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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 collecting data from a client who is receiving vancomycin for a Clostridium difficile infection.Which of the following findings is the priority for the nurse to report to the provider?

Correct Answer is D

Explanation

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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?