A nurse is caring for a client who is taking triamterene. For which of the following laboratory values should the nurse withhold the medication?

BUN 16 mg/dL

Potassium 5.3 mEq/L

Sodium 142 mEq/L

Albumin 4 g/Dl

Answer and Explanation

The Correct Answer is B

Choice A rationale:

BUN (blood urea nitrogen) measures kidney function and hydration status but is not a specific indicator for withholding triamterene.

Choice B rationale:

Triamterene is a potassium-sparing diuretic. With a potassium level of 5.3 mEq/L, which is elevated, the nurse should withhold the medication to prevent further potassium retention.

Choice C rationale:

Sodium level of 142 mEq/L is within the normal range and does not indicate a need to withhold triamterene.

Choice D rationale:

Albumin level of 4 g/dL is within the normal range and does not directly impact the decision to withhold triamterene.

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Correct Answer is A,B,C,D

Explanation

Choice A rationale:

The first step is to remove the medication from the dispensing system. This ensures that the nurse has the right medication and dose for the client. The nurse should also check the label of the medication against the medication administration record (MAR) at this point. Choice B rationale:

The second step is to compare the client's wristband to the MAR. This verifies the client's identity and prevents medication errors. The nurse should use two identifiers, such as name and date of birth, to confirm the client's identity.

Choice C rationale:

The third step is to open the medication package. This prepares the medication for administration and prevents contamination. The nurse should also check the expiration date of the medication before opening it.

Choice D rationale:

The fourth step is to document administration of the medication. This completes the medication administration process and provides a record of the client's care. The nurse should document the medication name, dose, route, time, and any relevant observations or outcomes.

A. Red man syndrome B. Hypotension C. Hypoglycemia D. Bradycardia

Correct Answer is B

Explanation

Choice A rationale:

Red man syndrome is typically associated with the rapid infusion of vancomycin, not phenytoin.

Choice B rationale:

Hypotension can be an adverse effect of phenytoin administration, especially if the medication is administered rapidly.

Choice C rationale:

Hypoglycemia is not commonly associated with phenytoin use.

Choice D rationale:

Bradycardia is not commonly associated with phenytoin use.

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A nurse is caring for a client who is taking triamterene. For which of the following laboratory values should the nurse withhold the medication?

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