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

D) Oxycodone causes central nervous system depression: Oxycodone is an opioid analgesic that acts centrally on the central nervous system (CNS) to relieve pain. One of the most significant side effects of opioids like oxycodone is respiratory depression, which occurs due to the suppression of the CNS, particularly in the brainstem respiratory centers. The brainstem regulates respiratory rate and rhythm, and when opioids depress these centers, it can lead to decreased respiratory drive, resulting in a decrease in respiratory rate. A respiratory rate of 8/min is significantly below the normal range, indicating respiratory depression caused by oxycodone.

A) Oxycodone inhibits prostaglandin synthesis: Oxycodone does not directly inhibit prostaglandin synthesis. Prostaglandins are lipid compounds with various physiological effects, including inflammation and pain modulation. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, inhibit prostaglandin synthesis by blocking cyclooxygenase enzymes. However, oxycodone primarily acts on opioid receptors in the CNS to relieve pain, rather than through prostaglandin inhibition.

B) Oxycodone promotes vasodilation of cranial arteries: While opioids can cause peripheral vasodilation, particularly in large doses, the primary mechanism of action of oxycodone is not through the promotion of vasodilation of cranial arteries. Vasodilation may occur as a side effect of opioid use, but it is not the primary cause of respiratory depression associated with oxycodone.

C) Oxycodone blocks the sodium channel suspending nerve conduction: This statement describes the mechanism of action of local anesthetics, such as lidocaine, which block sodium channels to inhibit nerve conduction. However, oxycodone is not a sodium channel blocker. Its analgesic effects result from binding to opioid receptors in the CNS, particularly mu-opioid receptors, rather than blocking sodium channels. Therefore, this option is not the pathophysiology for the respiratory rate of 8/min observed in the client receiving oxycodone.

A. The client has an increased creatinine level. B. The client is experiencing hypotension. C. The client's IV site is red and edematous. D. The c’ient reports ringing in their ears.

Correct Answer is B

Explanation

A) The client has an increased creatinine level: While an increased creatinine level may indicate renal impairment, it is not specific to a vancomycin infusion reaction. Elevated creatinine levels may occur due to various factors, including underlying kidney disease or dehydration.

B) The client is experiencing hypotension: This is the correct answer. Hypotension, or low blood pressure, can be a manifestation of a vancomycin infusion reaction. Vancomycin infusion reactions may include anaphylaxis or anaphylactoid reactions, which can lead to systemic vasodilation and subsequent hypotension.

C) The client's IV site is red and edematous: Redness ’nd edema at the IV site may indicate phlebitis or infiltration, which are local complications rather than systemic reactions to vancomycin infusion.

D) The client reports ringing in their ears: Ringing in the ears, also known as tinnitus, is a potential side effect of vancomycin, particularly with high doses or prolonged use. However, it is not specific to a vancomycin infusion reaction and may occur independently of the infusion process.

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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 assessing a client who has received oxycodone. The nurse notes that the client's respiratory rate is 8/min. The nurse should identify that which of the following is the pathophysiology for the client's respiratory rate?

Correct Answer is D

Explanation

A nurse is caring for a client who is receiving vancomycin by IV infusion over 30 min. Which of the following findings indicate the clien experiencing a vancomycin infusion reaction?

Correct Answer is B

Explanation

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