A nurse is reviewing the laboratory findings of a client who has liver failure with ascites. The client takes spironolactone. Which of the following findings is an adverse effect of themedication?

Serum chloride 99 mEq/L

Serum calcium 10.5 mg/dL

Serum potassium 5.2

Serum sodium 140 mEq/L.

Answer and Explanation

The Correct Answer is C

a. Serum chloride 99 mEq/L: Serum chloride within the reference range is not an adverse effect of spironolactone.

b. Serum calcium 10.5 mg/dL: Serum calcium within the reference range is not an adverse effect of spironolactone.

c. Serum potassium 5.2: Spironolactone is a potassium-sparing diuretic, and an elevated serum potassium level is an adverse effect that requires monitoring. The nurse should assess for

hyperkalemia.

d. Serum sodium 140 mEq/L: Serum sodium within the reference range is not an adverse effect of spironolactone.

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Correct Answer is A

Explanation

a. Provide humidified oxygen: Humidification helps prevent the drying of mucous membranes, making secretions more manageable and less tenacious. This is an acceptable method to thin

secretions in a client with a tracheostomy.

b. Prelubricate the suction catheter tip with sterile saline when suctioning the airway: While lubrication with sterile saline is a common practice during suctioning to reduce trauma to the airway, it does not directly address the tenacity of secretions.

c. Perform chest physiotherapy prior to suctioning: Chest physiotherapy is a technique used to mobilize respiratory secretions, but it may not directly address the tenacity of secretions.

d. Hyperventilate the client with 100% oxygen before suctioning the airway: Hyperventilation with 100% oxygen is not a routine practice and may lead to respiratory alkalosis. Providing

humidified oxygen is a more appropriate approach.

A. Respiratory acidosis - The low pH (acidosis) and elevated PaCO2 suggest respiratory acidosis, which is caused by inadequate ventilation leading to an accumulation of carbon dioxide. B. Metabolic acidosis - Metabolic acidosis is characterized by a low pH and decreased HCO3. C. Respiratory alkalosis - Respiratory alkalosis is characterized by a high pH and low PaCO2, which is not consistent with the provided arterial blood gas values. D. Metabolic alkalosis - Metabolic alkalosis is characterized by a high pH and increased HCO3, which does not align with the given values.

Correct Answer is A

Explanation

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A nurse is reviewing the laboratory findings of a client who has liver failure with ascites. The client takes spironolactone. Which of the following findings is an adverse effect of themedication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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