the client on spironolactone aldactone has a potassium level of 56 meql what is the nurses priority action
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Nursing Elites

ATI RN

Physical Exam Cardiovascular System

1. The client on spironolactone (Aldactone) has a potassium level of 5.6 mEq/L. What is the nurse’s priority action?

Correct answer: A

Rationale: The correct answer is A: Hold the spironolactone and notify the healthcare provider. A potassium level of 5.6 mEq/L is high, indicating hyperkalemia. Spironolactone is a potassium-sparing diuretic that can further elevate potassium levels. Therefore, the priority action is to withhold the medication to prevent exacerbating hyperkalemia and notify the healthcare provider for further management. Option B is incorrect because administering potassium supplements would worsen the hyperkalemia. Option C is incorrect as continuing spironolactone can lead to a further increase in potassium levels. Option D is incorrect as increasing the dose of spironolactone would be inappropriate in the presence of elevated potassium levels.

2. What is a condition where the heart is unable to pump blood effectively, leading to a buildup of fluid in the lungs and other parts of the body?

Correct answer: A

Rationale: The correct answer is A: Heart failure. Heart failure occurs when the heart is unable to pump blood effectively, resulting in a buildup of fluid in the lungs and other parts of the body. Choice B, Cardiomyopathy, refers to diseases of the heart muscle, not specifically the inability to pump blood effectively. Choice C, Myocardial infarction, is a heart attack caused by a blocked blood supply to the heart muscle, not directly related to the heart's pumping efficiency. Choice D, Pulmonary edema, is a condition characterized by fluid accumulation in the lungs, often a consequence of heart failure but not the primary condition described in the question.

3. This is a procedure where a small mesh tube is inserted into an artery to keep it open and improve blood flow.

Correct answer: A

Rationale: Stent placement is a procedure where a small mesh tube (stent) is inserted into an artery to keep it open and improve blood flow, often following angioplasty.

4. Which condition is characterized by a chronic cough that produces mucus, often caused by long-term exposure to irritants?

Correct answer: A

Rationale: Chronic bronchitis is the correct answer. It is characterized by a long-term cough with mucus production, often caused by smoking or prolonged exposure to irritants. Tuberculosis (choice B) is a bacterial infection that primarily affects the lungs but does not usually present with a chronic cough as the main symptom. Asthma (choice C) is a chronic respiratory condition characterized by inflammation and narrowing of the airways, leading to wheezing and shortness of breath, but it does not typically cause chronic mucus production. Sinusitis (choice D) is inflammation of the sinuses and presents with symptoms like facial pain, nasal congestion, and post-nasal drip, but not specifically a chronic cough with mucus production.

5. This is a more accurate indicator of tissue perfusion. It represents the cardiac output in terms of liters per minute per square meter of body surface area. Its normal range is 2.4-4 L/min.

Correct answer: A

Rationale: The correct answer is A: Cardiac Index. Cardiac Index is a measure of cardiac output relative to body surface area, providing a more accurate assessment of tissue perfusion. It is calculated by dividing the cardiac output by the body surface area. The normal range for cardiac index is 2.4-4 L/min/m². Choice B, Stroke volume, refers to the amount of blood ejected by the heart in one contraction and is not adjusted for body surface area. Choice C, Ejection fraction, is the percentage of blood pumped out of the heart's ventricles with each contraction, not adjusted for body surface area. Choice D, Cardiac output, is the total volume of blood pumped by the heart per minute, without considering body surface area.

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