A serum potassium level of 3.2 mEq/L is reported for a patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) due. Choose the best nursing action.

Administer the furosemide, then notify the HCP of potassium results.

Administer both drugs, then notify the HCP of potassium results.

Withhold both drugs and explain to the patient that the medications are contraindicated with hyperkalemia.

Administer the spironolactone, then notify the HCP of potassium results.

Answer and Explanation

The Correct Answer is D

Choice A reason:
Administering furosemide in this scenario would further lower the serum potassium level, as furosemide is a loop diuretic known for causing potassium loss through urine. This action could worsen the patient’s hypokalemia, leading to severe complications such as cardiac arrhythmias. Therefore, administering furosemide in the presence of hypokalemia is inappropriate and could put the patient at significant risk.
Choice B reason:
Administering both spironolactone and furosemide together without addressing the hypokalemia would not be safe. While spironolactone is a potassium-sparing diuretic, combining it with furosemide could negate its potassium-sparing effects. Furthermore, administering furosemide when hypokalemia is present could cause further electrolyte imbalance. Proper evaluation of the patient's condition and selective administration of the medications are crucial in this case.
Choice C reason:
Withholding both medications and attributing the decision to contraindications with hyperkalemia is incorrect because the reported potassium level (3.2 mEq/L) reflects hypokalemia, not hyperkalemia. Misinterpreting the lab result could delay appropriate treatment, such as correcting the potassium level or safely administering a medication that would not exacerbate the hypokalemia. Proper communication with the healthcare provider is necessary for effective patient care.
Choice D reason:
Administering spironolactone is the best action in this scenario because it is a potassium-sparing diuretic. By administering spironolactone, the risk of worsening hypokalemia is minimized. Notifying the healthcare provider about the low potassium level ensures appropriate monitoring and any necessary interventions, such as potassium supplementation. This approach is both safe and effective in managing the patient’s current condition while adhering to standard nursing practices.

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Correct Answer is ["A","C","D"]

Explanation

Choice A reason: Unilateral edema is a common sign of DVT. This occurs due to the obstruction of blood flow in the affected vein, leading to fluid buildup in the tissue, which causes swelling. The swelling is usually confined to the area of the leg where the clot is located, making it an important diagnostic indicator. In DVT, the affected limb often appears swollen compared to the other limb, and this can be easily observed by the healthcare provider during the physical examination.

Choice B reason: Nausea is not typically associated with DVT. While nausea can occur due to various medical conditions, it is not a primary symptom of DVT. DVT primarily affects the circulatory system, leading to symptoms related to impaired blood flow, such as swelling, pain, and redness in the affected limb. Therefore, nausea is unlikely to be directly related to the presence of a blood clot in the deep veins of the leg.

Choice C reason: Groin discomfort can be a symptom of DVT, especially if the clot is located in the femoral vein. The femoral vein runs through the groin area, and a clot in this vein can cause pain and tenderness in the groin. This discomfort is due to the pressure and inflammation caused by the clot obstructing blood flow. Patients may report a dull or aching pain in the groin, which can be exacerbated by movement or pressure.

Choice D reason: Calf pain is a classic symptom of DVT. It often presents as cramping, soreness, or aching in the calf due to the presence of a blood clot in the deep veins of the leg. The pain is caused by the increased pressure and inflammation in the affected vein, which irritates the surrounding tissues. This symptom is a key indicator of DVT and should prompt further evaluation and diagnostic testing, such as an ultrasound, to confirm the presence of a clot.

A. Sedatives and opioids B. Alcohol use C. Untreated pain D. Sleep deprivation E. Sensory overload

Correct Answer is ["A","B","C","D","E"]

Explanation

Choice A reason: Sedatives and opioids are known to cause delirium, especially in older adults or those with compromised health. These medications can affect the central nervous system, leading to confusion and cognitive impairment.
Choice B reason: Alcohol use, particularly in combination with withdrawal, can lead to delirium. Alcohol affects neurotransmitter function and can cause significant changes in mental status when consumed in excess or withdrawn abruptly.
Choice C reason: Untreated pain can contribute to delirium, particularly in patients who are already vulnerable due to age or underlying health conditions. Pain can cause significant stress on the body and mind, leading to confusion and cognitive dysfunction.
Choice D reason: Sleep deprivation is a significant factor in the development of delirium. Lack of sleep can impair cognitive function and increase the risk of delirium, especially in hospitalized patients or those with pre-existing cognitive impairments.
Choice E reason: Sensory overload, such as exposure to loud noises, bright lights, or unfamiliar environments, can contribute to delirium. Patients with sensory impairments or those in unfamiliar settings are particularly at risk.

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A serum potassium level of 3.2 mEq/L is reported for a patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) due. Choose the best nursing action.

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","C","D"]

Explanation

Causative factors for the development of delirium include which of the following? Select all that apply.

Correct Answer is ["A","B","C","D","E"]

Explanation

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