The nurse is monitoring a client taking a potassium sparing diuretic. Which of the following findings would prompt the nurse to notify the health care provider?

Serum sodium level of 140 mEq/L

Blood pressure of 130/80 mmHg

Serum potassium level of 5.5 mEq/L

Serum potassium level of 3.5 mEq/L

Answer and Explanation

The Correct Answer is C

Choice A reason: Serum sodium level of 140 mEq/L is within the normal range of 135145 mEq/L. It does not indicate any adverse effect of the potassium sparing diuretic, which does not affect sodium excretion significantly. The nurse does not need to notify the health care provider about this finding.
Choice B reason: Blood pressure of 130/80 mmHg is slightly above the normal range of 120/80 mmHg, but it is not a cause for concern. The potassium sparing diuretic can lower the blood pressure by reducing the fluid volume and preventing sodium retention. The nurse should monitor the blood pressure regularly but does not need to notify the health care provider about this finding.
Choice C reason: Serum potassium level of 5.5 mEq/L is above the normal range of 3.55.0 mEq/L. It indicates hyperkalemia, which is a serious and potentially life-threatening complication of the potassium sparing diuretic. The potassium sparing diuretic can increase the potassium level by inhibiting its secretion in the distal tubule of the kidney. The nurse should notify the health care provider immediately and prepare to administer interventions such as calcium gluconate, insulin, or sodium bicarbonate to lower the potassium level and prevent cardiac arrhythmias.
Choice D reason: Serum potassium level of 3.5 mEq/L is at the lower end of the normal range of 3.55.0 mEq/L. It does not indicate any adverse effect of the potassium sparing diuretic, which does not cause potassium loss. The nurse does not need to notify the health care provider about this finding.

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Correct Answer is ["B","C"]

Explanation

Choice A reason: This is incorrect. Polydipsia is excessive thirst, which is a symptom of hyperglycemia (high blood sugar), not hypoglycemia (low blood sugar). People with hyperglycemia lose fluid through frequent urination and become dehydrated, which makes them thirsty.

Choice B reason: This is correct. Shaking is a common sign of hypoglycemia. It occurs because the body releases adrenaline and other hormones to raise blood sugar levels. Adrenaline causes the muscles to tremble or shake.

Choice C reason: This is correct. Confusion is another common sign of hypoglycemia. It occurs because the brain does not get enough glucose, which is its main source of energy. Low blood sugar can impair cognitive functions, such as memory, attention, and judgment.

Choice D reason: This is incorrect. Tachycardia is a rapid heart rate, which can be a symptom of both hypoglycemia and hyperglycemia. However, it is not a specific or reliable indicator of low blood sugar, as it can also be caused by other factors, such as stress, anxiety, caffeine, or medication.

Choice E reason: This is incorrect. Polyuria is excessive urination, which is another symptom of hyperglycemia, not hypoglycemia. People with hyperglycemia have high levels of glucose in their blood, which draws water from the cells and increases urine output.

A. Administering half of the scheduled dose of Colace B. Administering the scheduled dose of Colace C. Inserting a rectal tube to prevent excoriation D. Holding the scheduled dose of Colace and notifying the ordering physician

Correct Answer is D

Explanation

Choice A reason: Administering half of the scheduled dose of Colace is not the correct action for the nurse who is caring for a patient who had two loose stools during the night shift. Colace is the brand name of docusate, which is a stool softener that works by increasing the amount of water and fat in the stool, making it easier to pass. Colace is used to treat and prevent constipation, which is a condition of infrequent or hard bowel movements. Colace is not indicated for diarrhea, which is a condition of frequent and loose bowel movements. Administering half of the scheduled dose of Colace may not be enough to prevent constipation, and it may also worsen diarrhea by adding more water and fat to the stool.

Choice B reason: Administering the scheduled dose of Colace is not the correct action for the nurse who is caring for a patient who had two loose stools during the night shift. Colace is the brand name of docusate, which is a stool softener that works by increasing the amount of water and fat in the stool, making it easier to pass. Colace is used to treat and prevent constipation, which is a condition of infrequent or hard bowel movements. Colace is not indicated for diarrhea, which is a condition of frequent and loose bowel movements. Administering the scheduled dose of Colace may not be necessary to prevent constipation, and it may also worsen diarrhea by adding more water and fat to the stool.

Choice C reason: Inserting a rectal tube to prevent excoriation is not the correct action for the nurse who is caring for a patient who had two loose stools during the night shift. A rectal tube is a device that is inserted into the rectum and connected to a drainage bag, which collects the stool and prevents leakage and skin irritation. A rectal tube is used for patients who have fecal incontinence, which is the inability to control bowel movements. A rectal tube is not indicated for patients who have diarrhea, which is a condition of frequent and loose bowel movements. Inserting a rectal tube may not be effective to prevent excoriation, and it may also cause complications such as infection, bleeding, or perforation.

Choice D reason: Holding the scheduled dose of Colace and notifying the ordering physician is the correct action for the nurse who is caring for a patient who had two loose stools during the night shift. Colace is the brand name of docusate, which is a stool softener that works by increasing the amount of water and fat in the stool, making it easier to pass. Colace is used to treat and prevent constipation, which is a condition of infrequent or hard bowel movements. Colace is not indicated for diarrhea, which is a condition of frequent and loose bowel movements. Holding the scheduled dose of Colace may be appropriate to avoid further diarrhea, and notifying the ordering physician may be necessary to determine the cause and the treatment of diarrhea

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The nurse is monitoring a client taking a potassium sparing diuretic. Which of the following findings would prompt the nurse to notify the health care provider?

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Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia? (Select all that apply.)

Correct Answer is ["B","C"]

Explanation

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Correct Answer is D

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