A nurse is caring for a client who has prescriptions for spironolactone and lisinopril. The nurse should monitor for which of the following adverse effects?

Hypoglycemia

Hyperkalemia

Hyperglycemia

Hypokalemia

Answer and Explanation

The Correct Answer is B

A. Hypoglycemia. Neither spironolactone nor lisinopril directly affects blood glucose levels. Hypoglycemia is more commonly associated with insulin, sulfonylureas (e.g., glipizide), and excessive alcohol consumption, rather than potassium-sparing diuretics or ACE inhibitors.

B. Hyperkalemia. Spironolactone is a potassium-sparing diuretic that promotes sodium excretion while retaining potassium, increasing the risk of hyperkalemia. Lisinopril, an ACE inhibitor, also raises potassium levels by reducing aldosterone secretion, which normally promotes potassium excretion. The combination of these two medications significantly increases the risk of dangerously high potassium levels, which can lead to cardiac arrhythmias, muscle weakness, and life-threatening complications. Clients should have serum potassium levels monitored regularly and be advised to avoid potassium-rich foods and supplements.

C. Hyperglycemia. Neither medication is known to cause hyperglycemia. Thiazide and loop diuretics are more likely to elevate blood glucose levels due to their effects on insulin sensitivity, but spironolactone and lisinopril do not share this effect.

D. Hypokalemia. Spironolactone prevents potassium loss, and lisinopril reduces potassium excretion, making hypokalemia unlikely. Hypokalemia is more commonly seen with loop diuretics (e.g., furosemide) and thiazide diuretics (e.g., hydrochlorothiazide), which promote potassium loss.

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Correct Answer is B

Explanation

A. Restart the infusion in the other extremity. While the IV infusion will need to be restarted in a new site, the priority after discontinuing the infusion is to manage the complications of IV infiltration. Restarting the infusion should be done after addressing the swelling and discomfort in the affected limb.

B. Elevate the extremity. Elevating the extremity reduces swelling and promotes fluid reabsorption following an IV infiltration. This helps minimize pain, tissue damage, and further complications, such as compartment syndrome. It is the next priority action after stopping the infusion.

C. Remove the catheter. The catheter should already be removed when the infusion is discontinued due to suspected infiltration. Keeping it in place could worsen tissue swelling and damage. If the catheter has not been removed yet, doing so is essential, but managing swelling and discomfort remains the priority after removal.

D. Apply warm, moist compresses to the site. Warm compresses are typically used for extravasation of non-vesicant solutions to promote circulation and absorption. However, in cases of severe infiltration or swelling, cold compresses may be used initially to reduce inflammation before applying warmth. The priority action is elevation, followed by applying appropriate compresses based on facility protocol.

A. The client had a local reaction from a previous immunization B. The client reports having diarrhea this morning C. The client is at 9 weeks of gestation D. The client reports an allergy to penicillin.

Correct Answer is C

Explanation

A. The client had a local reaction from a previous immunization. A mild local reaction, such as redness or swelling at the injection site, is not a contraindication to receiving the MMR vaccine. These reactions are common and typically resolve without complications. Only severe allergic reactions, such as anaphylaxis, would warrant withholding the vaccine.

B. The client reports having diarrhea this morning. Mild illnesses, such as diarrhea or the common cold, do not contraindicate vaccination. The MMR vaccine can be safely administered as long as the client does not have a moderate to severe illness with fever. Delaying immunization due to minor illnesses could lead to unnecessary gaps in vaccine coverage.

C. The client is at 9 weeks of gestation. The MMR vaccine is a live attenuated vaccine and is contraindicated during pregnancy due to the theoretical risk of fetal harm. Pregnant individuals should wait until after delivery to receive the vaccine. If a client of childbearing age is vaccinated, they should be advised to avoid pregnancy for at least 4 weeks following immunization to reduce the risk of congenital rubella syndrome.

D. The client reports an allergy to penicillin. A penicillin allergy is not a contraindication for the MMR vaccine. The MMR vaccine does not contain penicillin or related antibiotics. Severe allergic reactions to vaccine components, such as neomycin or gelatin, would be more relevant contraindications. Clients with a penicillin allergy can safely receive the MMR vaccine without concern.

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A nurse is caring for a client who has prescriptions for spironolactone and lisinopril. The nurse should monitor for which of the following adverse effects?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving a continuous IV infusion and reports pain at the IV insertion site. The nurse observes the arm is swollen and cool to touch. After discontinuing the infusion, which of the following actions should the nurse take next?

Correct Answer is B

Explanation

A nurse in a clinic is preparing to administer the measles, mumps, rubella (MMR) vaccine to a client. Which of the following findings should indicate to the nurse that the client has a contraindication for the MMR vaccine?

Correct Answer is C

Explanation

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