The nurse is preparing to administer spironolactone (Aldactone) and furosemide (Lasix) at 0900 to a client diagnosed with ascites. Review of 0600 laboratory results shows serum sodium 130 mEq/L (136-145 mEq/L) and potassium 3.1 mEq/L (3.5-5.0 mEq/L). Which action should the nurse take first?
Request a dietary consult
Order a 2 gram sodium restriction diet
Initiate a fluid restriction
Hold the spironolactone and furosemide
The Correct Answer is D
A) Requesting a dietary consult is useful but not the most immediate action needed.
B) Ordering a 2 gram sodium restriction diet is important but not addressing the immediate issue of electrolyte imbalance.
C) Fluid restriction may be considered but not before addressing the electrolyte issues.
D) Holding the spironolactone and furosemide is the correct action, as administering these could exacerbate the existing hypokalemia and hyponatremia, increasing the risk of adverse effects.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Chronic damage to the pancreas can lead to diabetes mellitus due to the destruction of insulin-producing cells.
B) Jaundice is typically associated with liver disease, not directly linked with chronic pancreatitis.
C) Ascites is a complication of liver disease, not typically a direct result of chronic pancreatitis.
D) While steatorrhea is a symptom of chronic pancreatitis due to malabsorption of fats, it is not a complication but rather a direct effect of the enzyme insufficiency.
Correct Answer is B
Explanation
A) Pancreatic enzymes are typically used to aid in digestion rather than pain control in acute pancreatitis.
B) Decompression of the gastrointestinal tract through nasogastric suction can help reduce pancreatic stimulation and alleviate pain in acute pancreatitis.
C) While ambulation may help prevent complications, it is not directly related to pain control in acute pancreatitis.
D) A clear liquid diet may be initiated once the acute phase has resolved, but it does not directly contribute to pain control.
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