A nurse is caring for a client who has cirrhosis of the liver and is receiving spironolactone. Which of the following findings indicates that the client is responding to the treatment?

Increased appetite

Decreased jaundice

Increased energy

Decreased ascites

Answer and Explanation

The Correct Answer is D

A. Increased appetite can be a positive sign but is not a direct indicator of spironolactone’s effectiveness in treating cirrhosis-related complications.
B. Decreased jaundice is a positive sign but is not the primary indicator of spironolactone’s effectiveness. Jaundice is more directly related to liver function.
C. Increased energy can indicate overall improvement but is not specific to the effects of spironolactone.
D. Decreased ascites is a direct indicator that spironolactone is effective. Spironolactone is a diuretic used to reduce fluid accumulation in the abdomen (ascites) associated with liver cirrhosis. A reduction in ascites indicates that the medication is working as intended.

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Correct Answer is D

Explanation

A. Frequency is clearly stated as every 12 hours, which is a common dosing interval for ondansetron. There is no need to clarify this part of the prescription.
B. Route is specified as by mouth, which is an appropriate and common route of administration for ondansetron. This part of the prescription does not require clarification.
C. Dose is specified as 8 mg, which is within the typical dosing range for ondansetron. There is no need to clarify this part of the prescription.
D. Reason is not specified in the prescription. PRN (as needed) medications should include the specific indication for use to ensure safe and appropriate administration. The nurse should clarify with the provider under what circumstances the ondansetron should be given, such as for nausea or vomiting.

A. Give diphenhydramine IM. B. Elevate the client’s legs and feet. C. Administer epinephrine IM. D. Replace the infusion with 0.9% sodium chloride.

Correct Answer is C

Explanation

A. Give diphenhydramine IM. This action is incorrect because while diphenhydramine can help manage allergic reactions, it is not the first-line treatment for anaphylaxis. Epinephrine is the priority medication for anaphylactic reactions.
B. Elevate the client’s legs and feet. This action is incorrect because while elevating the legs can help with shock, it is not the immediate priority in anaphylaxis. Administering epinephrine is the most critical step.
C. Administer epinephrine IM. This action is correct because epinephrine is the first-line treatment for anaphylaxis. It helps to reverse the severe symptoms of anaphylaxis, including airway constriction and low blood pressure.
D. Replace the infusion with 0.9% sodium chloride. This action is incorrect because while replacing the infusion can help maintain fluid balance, it is not the immediate priority. Administering epinephrine is the most critical step.

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A nurse is caring for a client who has cirrhosis of the liver and is receiving spironolactone. Which of the following findings indicates that the client is responding to the treatment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Explanation

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