the client on spironolactone aldactone has a potassium level of 58 meql what is the nurses priority action the client on spironolactone aldactone has a potassium level of 58 meql what is the nurses priority action
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Nursing Elites

ATI RN

Cardiovascular System Exam

1. The client on spironolactone (Aldactone) has a potassium level of 5.8 mEq/L. What is the nurse’s priority action?

Correct answer: A

Rationale: With a potassium level of 5.8 mEq/L, which is high, the priority action for the nurse is to hold the spironolactone. Spironolactone is a potassium-sparing diuretic that can further increase potassium levels. Therefore, it is crucial to prevent exacerbating hyperkalemia by discontinuing the medication. Notifying the healthcare provider is necessary for further guidance and potential adjustments to the treatment plan. Administering a potassium supplement (Choice B) would be contraindicated since the client already has elevated potassium levels. Continuing the spironolactone as ordered (Choice C) can worsen hyperkalemia. Increasing the dose of spironolactone (Choice D) would be unsafe and exacerbate the high potassium levels.

2. A clinic nurse is working with a patient who has a long-standing diagnosis of polycythemia vera. How can the nurse best gauge the course of the patient's disease?

Correct answer: D

Rationale: The course of polycythemia vera can be best ascertained by monitoring the patient's hematocrit, which should remain below 45%. Hematocrit levels are a key indicator in assessing the progression of the disease. Choices A, B, and C are not the most appropriate methods for gauging the course of polycythemia vera. Monitoring the color of the patient's palms and face, or their response to erythropoietin injections, may not provide an accurate reflection of the disease's progression. Similarly, while erythrocyte sedimentation rate can be affected in polycythemia vera, it is not the primary marker for monitoring the disease's course.

3. During an assessment, a client is demonstrating symptoms of moderate anxiety. Which of the following symptoms would be indicative of moderate anxiety?

Correct answer: C

Rationale: Palpitations are a common physical symptom seen in clients experiencing moderate anxiety. Fidgeting, laughing inappropriately, and nail biting can also indicate heightened stress levels. It's important for healthcare providers to recognize these signs and provide appropriate support. While anxiety can manifest in various ways, other indicators of moderate anxiety may include restlessness, difficulty concentrating, muscle tension, and sleep disturbance. It's crucial for healthcare providers to assess these symptoms to provide effective care and interventions. Laughing inappropriately and nail biting are more commonly associated with nervousness or social discomfort, while fidgeting may signal mild anxiety.

4. A client has a new prescription for Levofloxacin. Which of the following instructions should be included in the discharge instructions?

Correct answer: B

Rationale: The correct answer is B: 'Avoid taking this medication with dairy products.' Levofloxacin should not be taken with dairy products because calcium can interfere with the absorption of the medication. It is recommended to take Levofloxacin 1 hour before or 2 hours after consuming dairy products to ensure optimal absorption and effectiveness of the medication. Choices A, C, and D are incorrect. Choice A is not recommended as Levofloxacin is usually taken on an empty stomach. Choice C is not necessary information for taking Levofloxacin. Choice D is unrelated to the administration of Levofloxacin.

5. How do socioeconomic factors influence mental health?

Correct answer: B

Rationale: Socioeconomic factors are indeed primary determinants of mental health. These factors influence mental health by impacting access to resources, stress levels, and overall well-being. Choice A is incorrect as socioeconomic factors do have a significant impact on mental health. Choice C is incorrect as socioeconomic factors play a crucial role in mental health outcomes. Choice D is incorrect as socioeconomic factors can both exacerbate and cause mental health issues.

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