a client with liver cirrhosis and ascites is being treated with spironolactone what is a key nursing consideration for this medication
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Nursing Elites

ATI LPN

Medical Surgical ATI Proctored Exam

1. A client with liver cirrhosis and ascites is being treated with spironolactone. What is a key nursing consideration for this medication?

Correct answer: A

Rationale: Spironolactone is a potassium-sparing diuretic, which can lead to hyperkalemia as it helps retain potassium in the body. Therefore, monitoring for signs of hyperkalemia such as muscle weakness, arrhythmias, or ECG changes is crucial to prevent potential complications.

2. The nurse is caring for a client with a spinal cord injury. Which intervention should the nurse implement to prevent autonomic dysreflexia?

Correct answer: C

Rationale: To prevent autonomic dysreflexia in clients with spinal cord injuries, it is crucial to ensure the client's bladder is emptied regularly. Bladder distention is a common trigger for autonomic dysreflexia in these clients. Keeping the bladder empty helps prevent the complications associated with autonomic dysreflexia, such as dangerously high blood pressure. Choices A, B, and D are incorrect. Restricting fluid intake can lead to dehydration, keeping the room warm is not directly related to preventing autonomic dysreflexia, and limiting high-fiber foods is not a primary intervention for this condition.

3. A client with Parkinson's disease is being cared for by a nurse. Which intervention should be included to address the client's bradykinesia?

Correct answer: A

Rationale: Encouraging daily walking is an essential intervention to address bradykinesia in clients with Parkinson's disease. Walking helps improve mobility, flexibility, and coordination, which can help manage the slowness of movement associated with bradykinesia. Providing thickened liquids (Choice B) is more relevant for dysphagia, not bradykinesia. Offering small, frequent meals (Choice C) is related to managing dysphagia and nutritional needs but does not specifically address bradykinesia. Teaching the client to use adaptive utensils (Choice D) is more focused on addressing fine motor skills and grip strength, which are not the primary concerns in bradykinesia.

4. An 89-year-old male client complains to the nurse that people are whispering behind his back and mumbling when they talk to him. What age-related condition is likely to be occurring with this client?

Correct answer: C

Rationale: The correct answer is C, Presbycusis. Presbycusis is age-related hearing loss that often affects the ability to hear high-pitched sounds, making speech appear mumbled. This condition is common in older adults and can lead to difficulties in understanding conversations, as in the case of the client complaining about people whispering and mumbling.

5. A patient is being cared for after bariatric surgery, and the healthcare provider is assessing for hemorrhage. What is a sign of hemorrhage?

Correct answer: B

Rationale: Frank red bleeding from the surgical site is a significant sign of hemorrhage that warrants immediate attention. It indicates active bleeding that needs to be addressed promptly to prevent further complications.

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