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 energy

Decreased ascites

Increased appetite

Decreased jaundice

Answer and Explanation

The Correct Answer is B

A) Increased energy: While increased energy could be a positive outcome of treatment, it is not a specific indicator of the client's response to spironolactone therapy for’cirrhosis.

B) Decreased ascites: This is the correct answer. Spironolactone, a potassium-sparing diuretic, is commonly used to treat ascites in clients with cirrhosis by promoting diuresis and reducing fluid retention in the abdomen. Therefore, a decrease in ascites indicates a positive response to spironolactone therapy.

C) Increased appetite: Increased appetite is not typically a direct response to spironolactone therapy for cirrhosis. It may be influenced by various factors and is not specific to the client's response to the medication.

D) Decrea’ed jaundice: While spironolactone may indirectly help improve liver function, decrease fluid retention, and alleviate symptoms of cirrhosis, it is not primarily used to address jaundice. Other interventions and treatments may be necessary to manage jaundice in clients with liver cirrhosis.

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Correct Answer is D

Explanation

A) Discontinue the infusion: While discontinuing the parenteral nutrition infusion may be necessary in severe cases of hypoglycemia, it should not be the initial action unless the client's condition warrants it. Discontinuing the infusion without providing alternative sources of glucose may exacerbate the hypoglycemia and lead to further complications.

B) Obtain arterial blood gases: Arterial blood gases (ABGs) are not typically indicated for evaluating hypoglycemia. While ABGs provide valuable information about acid-base balance and oxygenation status, they do not directly assess blood glucose levels or contribute to the management of hypoglycemia.

C) Warm formula to room temperature: Warming the parenteral nutrition formula to room temperature may improve comfort during administration, but it is not directly related to managing hypoglycemia. Hypoglycemia requires prompt intervention to raise blood sugar levels, and warming the formula would not address the immediate need for glucose supplementation.

D) Administer IV dextrose: Hypoglycemia is a potentially serious complication of parenteral nutrition administration, especially if the infusion rate is too high or if the client's metabolic needs are not adequately met. IV dextrose, a concentrated glucose solution, is the most appropriate intervention for treating hypoglycemia in this situation. It provides a rapid source of glucose to raise blood sugar levels quickly and effectively.

A. Grasp skin between thumb and forefinger throughout the injection. B. Aspirate the syringe prior to injecting the heparin. C. Use the Z-track method to administer the medication. D. Gently massage the site following the injection.

Correct Answer is A

Explanation

A) Grasp skin between thumb and forefinger throughout the injection: This is the correct answer. Grasping the skin between the thumb and forefinger creates tension, which helps to stabilize the tissue during the injection. This technique reduces the risk of tissue damage and minimizes bleeding following the injection of heparin subcutaneously.

B) Aspirate the syringe prior to injecting the heparin: Aspiration is not necessary for subcutaneous injections, as the risk of intravascular injection is minimal. Aspirating the syringe can increase discomfort for the client and is not recommended for subcutaneous injections.

C) Use the Z-track method to administer the medication: The Z-track method is used for intramuscular injections to minimize medication leakage into the subcutaneous tissue. However, heparin is typically administered subcutaneously, and the Z-track method is not appropriate for this route of administration.

D) Gently massage the site following the injection: Massaging the site following a subcutaneous injection of heparin can increase the risk of bleeding and hematoma formation. Therefore, this action should be avoided to minimize bleeding at the injection site.

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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

A nurse is caring for a client who is receiving parenteral nutrition and identifies that the client has hypoglycemia. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nu’se is preparing to administer heparin subcutaneously to a client. Which of the following actions should the nurse plan to take to minimize bleeding following the injection?

Correct Answer is A

Explanation

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