NCLEX - Week 10 Flashcards
A nurse is caring for a client who is receiving furosemide intravenously for acute pulmonary edema. Which of the following assessments is the for the nurse to perform?
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A. Auscultate bowel sounds
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B. Monitor intake and output
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C. Assess for dependent edema
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D. Monitor blood pressure and heart rate
D. Monitor blood pressure and heart rate.
Rationale:
Furosemide is a potent loop diuretic that can cause rapid fluid shifts and electrolyte imbalances, potentially leading to hypotension. Monitoring blood pressure and heart rate is crucial to assess for these complications, especially in a client with acute pulmonary edema where hemodynamic stability is paramount.
A client with heart failure is prescribed spironolactone. Which of the following statements by the client indicates a need for further teaching?
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A. “I should avoid foods high in potassium.”
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B. “I can expect my urine output to increase significantly.”
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C. “I need to have my potassium levels checked regularly.”
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D. “This medication will help reduce fluid buildup in my body.”
B. “I can expect my urine output to increase significantly.”
Rationale:
Spironolactone is a potassium-sparing diuretic with a weaker diuretic effect compared to loop or thiazide diuretics. While it helps reduce fluid retention, the increase in urine output is not as pronounced as with other diuretic classes.
A nurse is administering hydrochlorothiazide to a client with hypertension. Which of the following instructions should the nurse include in the client’s teaching?
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A. “Take this medication in the evening to prevent nighttime urination.”
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B. “You may experience some ringing in your ears as a side effect.”
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C. “Increase your intake of potassium-rich foods while taking this medication.”
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D. “You can stop taking this medication once your blood pressure is normal.”
C. “Increase your intake of potassium-rich foods while taking this medication.”
Rationale:
Hydrochlorothiazide is a thiazide diuretic that can cause potassium loss (hypokalemia). Consuming potassium-rich foods is important to prevent this side effect. Taking the medication in the evening could cause nocturia, ringing in the ears is a sign of ototoxicity (associated with loop diuretics, not thiazides), and stopping the medication abruptly can lead to rebound hypertension.
A client with increased intracranial pressure is receiving mannitol. Which of the following findings should the nurse report to the provider immediately?
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A. Urine output of 35 mL/hour
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B. Blood glucose level of 140 mg/dL
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C. Heart rate of 110 beats per minute
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D. New onset of crackles in the lungs
D. New onset of crackles in the lungs
Rationale:
Mannitol is an osmotic diuretic that can cause fluid shifts. Crackles in the lungs can indicate pulmonary edema, a serious adverse effect of mannitol, especially in clients with compromised cardiac function or fluid overload.
Which of the following diuretics is most likely to cause ototoxicity?
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A. Spironolactone
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B. Hydrochlorothiazide
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C. Mannitol
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D. Furosemide
D. Furosemide
Rationale:
Loop diuretics, including furosemide, are known to cause ototoxicity, a potentially serious adverse effect resulting in hearing impairment. While usually transient, this side effect requires careful monitoring
A client receiving a thiazide diuretic should be taught to do which of the following?
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A. Take the medication at bedtime to prevent nocturia
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B. Avoid foods that are high in potassium
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C. Monitor their blood glucose levels closely
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D. Restrict their fluid intake to prevent fluid overload
C. Monitor their blood glucose levels closely
Rationale:
Thiazide diuretics can cause hyperglycemia, so clients with diabetes should monitor their blood glucose levels carefully.
Which of the following statements about loop diuretics is accurate?
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A. They work by blocking aldosterone in the distal nephron
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B. They are less potent than thiazide diuretics
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C. They can be effective even in clients with reduced kidney function
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D. They are the first-line treatment for mild hypertension
C. They can be effective even in clients with reduced kidney function
Rationale:
Loop diuretics are effective even when glomerular filtration rate (GFR) is low, unlike thiazide diuretics. They work in the loop of Henle, not by blocking aldosterone. Loop diuretics are more potent than thiazide diuretics, and are often reserved for situations where thiazides are ineffective, such as severe edema or hypertension.
Which electrolyte imbalance is a common side effect of both loop and thiazide diuretics?
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A. Hyperkalemia
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B. Hypocalcemia
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C. Hypokalemia
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D. Hypernatremia
C. Hypokalemia
Rationale:
Both loop and thiazide diuretics increase potassium excretion, which can lead to hypokalemia.
A nurse is caring for a client who is receiving intravenous potassium chloride. Which is the most important nursing intervention?
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A. Monitor the client’s urine output
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B. Administer the infusion over 15 minutes
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C. Check the client’s blood pressure frequently
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D. Use an infusion pump and monitor the site frequently
D. Use an infusion pump and monitor the site frequently
Rationale:
Intravenous potassium chloride is a high-alert medication that must be administered with extreme caution. It must be diluted and infused slowly using an infusion pump to prevent cardiac complications. Frequent monitoring of the IV site for infiltration or phlebitis is essential.
A client is taking spironolactone and lisinopril. Which of the following electrolytes should be monitored closely by the nurse?
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A. Sodium
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B. Chloride
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C. Calcium
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D. Potassium
D. Potassium
Rationale:
Spironolactone is a potassium-sparing diuretic, while lisinopril, an ACE inhibitor, can also increase potassium levels. Combining these medications increases the risk of hyperkalemia, requiring close monitoring of potassium levels.
A client diagnosed with hypertension is prescribed hydrochlorothiazide. The nurse determines that the client understands the teaching about this medication when the client states:
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A. “I should take this medication at bedtime.”
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B. “I should expect to urinate every hour while taking this medication.”
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C. “I need to avoid foods that are high in potassium.”
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D. “I should eat foods rich in potassium like bananas and potatoes.”
D. “I should eat foods rich in potassium like bananas and potatoes.”
Rationale:
Hydrochlorothiazide is a thiazide diuretic, which can cause hypokalemia. Consuming high-potassium foods helps prevent this.
Option A is incorrect as taking the medication at bedtime could lead to sleep disruption due to nocturia.
Option B is incorrect; while urination will increase, hourly urination is unlikely.
Option C is incorrect as clients should increase their potassium intake
A client with a history of congestive heart failure is being treated with furosemide. Which of the following electrolytes should the nurse monitor closely?
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A. Sodium and Potassium
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B. Calcium and Magnesium
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C. Phosphorus and Chloride
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D. Bicarbonate and Sulfate
A. Sodium and Potassium
Rationale:
Furosemide is a loop diuretic that causes loss of sodium, potassium, and water. Monitoring these electrolytes is crucial to prevent and detect electrolyte imbalances, especially hypokalemia and hyponatremia, which can have significant effects on the cardiovascular system.
Option B is partially correct, as furosemide can also cause hypocalcemia and hypomagnesemia, but sodium and potassium are the most critical electrolytes to monitor.
Options C and D are not directly affected by furosemide.
The nurse is educating a client about the potential adverse effects of furosemide. Which of the following side effects would be for the nurse to emphasize?
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A. Constipation
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B. Blurred vision
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C. Muscle weakness and cramping
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D. Metallic taste in the mouth
C. Muscle weakness and cramping
Rationale:
Muscle weakness and cramping are key signs of hypokalemia, a common and potentially serious adverse effect of furosemide.
Option A is not associated with furosemide. Option B is not a common side effect. Option D is not a typical side effect.
A client is receiving mannitol for increased intracranial pressure. The nurse knows that the medication is working when she assesses:
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A. Increased urine output and decreased blood pressure
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B. Decreased level of consciousness and fixed pupils
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C. Increased level of consciousness and decreased intracranial pressure
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D. Decreased urine output and decreased respiratory rate
C. Increased level of consciousness and decreased intracranial pressure
Rationale:
Mannitol is an osmotic diuretic used to reduce intracranial pressure. A reduction in intracranial pressure can improve neurological function, resulting in an increased level of consciousness.
Option A is partially correct as mannitol does increase urine output, but its effect on blood pressure is not the primary indicator of effectiveness for this condition.
Option B is incorrect and suggests worsening of the client’s condition.
Option D is incorrect, mannitol should increase urine o
A nurse is providing discharge instructions to a client prescribed spironolactone. Which statement by the client indicates a need for further education?
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A. “I will continue to monitor my blood pressure at home.”
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B. “I will use salt substitutes to flavor my food.”
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C. “I understand I need to have regular blood tests to check my potassium levels.”
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D. “I will be sure to call my provider if I experience any unusual side effects.”
B. “I will use salt substitutes to flavor my food.”
Rationale:
Many salt substitutes contain potassium chloride. Using salt substitutes while taking spironolactone can lead to hyperkalemia, a potentially dangerous condition.
Options A, C, and D demonstrate understanding of the medication and its potential side effects.
Which of the following is a potential adverse effect of all the diuretic classifications?
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A. Hyperkalemia
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B. Ototoxicity
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C. Hypoglycemia
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D. Dehydration
D. Dehydration
Rationale:
All diuretics promote urine production, potentially leading to dehydration if fluid intake is not adequate.
Option A is a risk primarily with potassium-sparing diuretics.
Option B is a risk specifically with loop diuretics.
Option C is not a typical adverse effect; hyperglycemia is more likely.
When administering IV furosemide, the nurse should:
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A. Administer the medication rapidly as a bolus.
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B. Monitor the client’s blood pressure closely.
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C. Encourage the client to restrict fluid intake.
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D. Expect the client’s urine output to decrease.
B. Monitor the client’s blood pressure closely.
Rationale:
IV furosemide can cause a rapid drop in blood pressure due to fluid shifts and vasodilation.
Option A is incorrect, IV furosemide should be administered slowly.
Option C is incorrect, clients need adequate fluid intake.
Option D is incorrect, furosemide should increase urine output.
A client is prescribed a potassium-sparing diuretic. Which of the following statements indicates that the client understands the medication instructions?
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A. “I should increase my intake of oranges and bananas.”
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B. “I need to avoid using salt substitutes.”
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C. “This medication will make me urinate a lot more.”
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D. “I can expect to experience some ringing in my ears.”
B. “I need to avoid using salt substitutes.”
Rationale:
Salt substitutes often contain potassium chloride. Clients taking potassium-sparing diuretics should avoid these to prevent hyperkalemia.
Option A is incorrect, as high-potassium foods should be limited with potassium-sparing diuretics.
Option C is incorrect; potassium-sparing diuretics have a modest diuretic effect. Option
D is incorrect, ringing in the ears is associated with loop diuretics.
The nurse is preparing to administer mannitol to a client with cerebral edema. Which of the following nursing actions is ?
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A. Use an infusion pump and monitor the IV site for extravasation.
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B. Warm the solution before administration to dissolve any crystals.
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C. Check the client’s urine for glucose before administering the medication.
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D. Assess the client’s serum potassium level before administering the medication.
B. Warm the solution before administration to dissolve any crystals.
Rationale: Mannitol can crystallize in solution, especially at low temperatures. Warming the solution ensures proper drug administration and prevents the infusion of crystals, which could damage blood vessels.
Option A is important for all IV medications but not the most critical for mannitol.
Options C and D are not necessary for mannitol administration.
A nurse is reviewing the laboratory results of a client taking furosemide. Which of the following results would be of to the nurse?
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A. Potassium level of 3.2 mEq/L
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B. Sodium level of 138 mEq/L
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C. Calcium level of 9.0 mg/dL
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D. Magnesium level of 1.8 mEq/L
A. Potassium level of 3.2 mEq/L
Rationale:
A potassium level of 3.2 mEq/L indicates hypokalemia, a common adverse effect of furosemide, and can lead to life-threatening cardiac arrhythmias.
Options B and C are within normal ranges.
Option D indicates mild hypomagnesemia, which can occur with furosemide but is less critical than hypokalemia
Which medication is a potassium-sparing diuretic and is frequently prescribed in combination with a thiazide diuretic to counteract potassium loss and enhance diuresis?
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A. Spironolactone
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B. Furosemide
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C. Mannitol
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D. Ethacrynic acid
A. Spironolactone
Rationale:
Spironolactone is a potassium-sparing diuretic frequently combined with thiazide diuretics to counter potassium loss and enhance diuresis.
Furosemide and ethacrynic acid are loop diuretics. Mannitol is an osmotic diuretic.
What statement describes a key difference between the actions of spironolactone and triamterene?
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A. Spironolactone directly inhibits the sodium-potassium exchange mechanism, while triamterene indirectly blocks aldosterone.
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B. Spironolactone leads to rapid diuresis, while triamterene’s diuretic effects are delayed.
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C. Spironolactone indirectly blocks aldosterone, while triamterene directly inhibits the sodium-potassium exchange mechanism.
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D. Spironolactone causes significant potassium loss, while triamterene promotes potassium retention.
C. Spironolactone indirectly blocks aldosterone, while triamterene directly inhibits the sodium-potassium exchange mechanism.
Rationale:
Spironolactone is an aldosterone antagonist that reduces ion transport indirectly by blocking aldosterone.
Triamterene directly inhibits the sodium-potassium exchange mechanism.
Both medications have delayed diuretic effects.
A client is prescribed furosemide for treatment of edema associated with chronic kidney disease. What laboratory values should be carefully monitored in this client?
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A. Blood Urea Nitrogen (BUN) and Creatinine
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B. White Blood Cell (WBC) Count and Hemoglobin
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C. Platelet Count and International Normalized Ratio (INR)
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D. Alanine Transaminase (ALT) and Aspartate Transaminase (AST)
A. Blood Urea Nitrogen (BUN) and Creatinine
Rationale:
BUN and creatinine levels reflect kidney function. In a client with chronic kidney disease receiving a diuretic, monitoring these values is essential to assess the impact of the medication on kidney function and overall fluid balance.
Options B, C, and D are not directly related to kidney function or diuretic therapy.
A client with hypertension is starting a new medication regimen that includes hydrochlorothiazide. What is the information to include in the client’s teaching about this medication?
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A. Avoid driving or operating machinery while taking this medication.
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B. Take the medication with food or milk to prevent stomach upset.
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C. Rise slowly from sitting or lying positions to avoid dizziness.
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D. Report any changes in hearing to your healthcare provider.
C. Rise slowly from sitting or lying positions to avoid dizziness.
Rationale:
Hydrochlorothiazide can cause orthostatic hypotension, leading to dizziness, lightheadedness, and falls, especially when rising from a seated or lying position.
Option A is not typically necessary unless the client experiences dizziness or lightheadedness.
Option B might be helpful if GI upset occurs but is not the most important instruction.
Option D applies to loop diuretics, not thiazides.
A client receiving mannitol for increased intraocular pressure begins to exhibit signs and symptoms of pulmonary edema. What should the nurse do first?
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A. Check the client’s serum electrolytes.
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B. Elevate the head of the bed and administer oxygen.
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C. Decrease the infusion rate of the mannitol.
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D. Stop the mannitol infusion and notify the healthcare provider.
D. Stop the mannitol infusion and notify the healthcare provider.
Rationale:
Pulmonary edema is a potentially life-threatening adverse effect of mannitol. The priority action is to immediately stop the infusion to prevent further fluid overload and notify the provider for further interventions.
Option A can be done after stopping the infusion, but it’s not the immediate priority.
Option B is a supportive measure, but stopping the mannitol infusion is crucial.
Option C might be insufficient; stopping the infusion is necessary to address the potential life-threatening complication.
What laboratory test should be ordered to assess the effectiveness of furosemide in treating a client with edema?
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A. Arterial Blood Gases (ABGs)
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B. Complete Blood Count (CBC)
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C. Urinalysis
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D. Daily weights
D. Daily weights
Rationale:
Daily weights are the most effective way to monitor fluid loss or gain in response to diuretic therapy.
Option A assesses respiratory function, not fluid status.
Option B is a general blood test and not specific to fluid status.
Option C provides information about urine composition but not overall fluid volume changes.
A client is receiving spironolactone. What information should be included in the client’s discharge teaching?
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A. “Increase your intake of potassium-rich foods.”
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B. “Report any muscle weakness or cramping to your healthcare provider.”
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C. “You can expect your urine to turn a bluish-green color.”
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D. “You should avoid consuming alcohol while taking this medication.”
B. “Report any muscle weakness or cramping to your healthcare provider.”
Rationale:
Spironolactone is a potassium-sparing diuretic. Muscle weakness or cramping could indicate hyperkalemia, a potential adverse effect.
Option A is incorrect, as potassium-rich foods should be limited with spironolactone.
Option C is associated with triamterene, not spironolactone.
Option D is a general precaution for many medications, but not specific to spironolactone.
A client with heart failure has been prescribed furosemide and digoxin. What is the intervention for the nurse to implement to prevent complications in this client?
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A. Assess the client’s apical pulse before administering digoxin.
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B. Monitor the client’s intake and output closely.
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C. Check the client’s serum potassium levels regularly.
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D. Administer the medications at least 2 hours apart.
C. Check the client’s serum potassium levels regularly.
Rationale:
Furosemide can cause hypokalemia, which increases the risk of digoxin toxicity. Monitoring potassium levels is crucial to prevent potentially life-threatening cardiac complications.
Option A is a routine nursing intervention for digoxin administration but not the most important in this scenario.
Option B is important but not specific to the interaction between furosemide and digoxin.
Option D does not address the interaction between the medications.
The nurse is preparing to administer intravenous potassium chloride to a client with hypokalemia. Which action by the nurse requires intervention by the charge nurse?
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A. The nurse prepares to administer the potassium chloride using an infusion pump.
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B. The nurse dilutes the potassium chloride in a 100 mL bag of normal saline.
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C. The nurse plans to administer the potassium chloride over 1 hour.
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D. The nurse checks the client’s urine output before administering the potassium chloride.
C. The nurse plans to administer the potassium chloride over 1 hour.
Rationale:
Intravenous potassium chloride should be administered slowly to prevent cardiac complications. Infusing it over 1 hour is too rapid and could lead to serious adverse effects.
Option A is correct; an infusion pump should always be used for IV potassium chloride.
Option B is correct; dilution is necessary for safe administration.
Option D is a prudent nursing action but not the primary safety concern.
Which diuretic exerts its effects by inhibiting sodium and chloride reabsorption in the loop of Henle, and is often used in emergency situations to manage pulmonary edema?
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A. Spironolactone
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B. Hydrochlorothiazide
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C. Furosemide
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D. Mannitol
C. Furosemide
Rationale:
Furosemide, a loop diuretic, inhibits sodium and chloride reabsorption in the loop of Henle, making it a powerful diuretic frequently employed in emergencies like pulmonary edema.
Spironolactone is a potassium-sparing diuretic.
Hydrochlorothiazide is a thiazide diuretic.
Mannitol is an osmotic diuretic.
The nurse is evaluating the effectiveness of hydrochlorothiazide in a client with mild heart failure. What assessment finding would indicate that the medication is achieving its therapeutic goal?
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A. Increased urine output
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B. Weight loss
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C. Decreased blood pressure
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D. Resolution of edema
D. Resolution of edema
Rationale:
The primary goal of hydrochlorothiazide in treating mild heart failure is to mobilize edema and reduce fluid retention. Resolution of edema indicates the medication is achieving its therapeutic effect.
While options A, B, and C might also be observed, they are not the most specific indicators of effectiveness for edema management.
A client receiving intravenous mannitol reports a severe headache. What is the nurse’s ?
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A. Administer a prescribed analgesic.
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B. Reassess the client’s neurological status.
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C. Slow the rate of the mannitol infusion.
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D. Notify the healthcare provider immediately.
D. Notify the healthcare provider immediately.
Rationale: A severe headache in a client receiving mannitol for increased intracranial pressure could indicate a rebound increase in pressure, a serious adverse effect. Prompt notification of the provider is essential for timely intervention.
While options A, B, and C might be appropriate, the priority is to alert the provider for assessment and potential medication adjustments.
The nurse knows that potassium-sparing diuretics can be used to treat all of the following conditions :
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A. Edema
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B. Severe renal impairment
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C. Hypertension
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D. Heart failure
B. Severe renal impairment
Rationale: Potassium-sparing diuretics are contraindicated in clients with severe kidney failure or anuria as they can lead to dangerous potassium retention.
Options A, C, and D are conditions treatable with potassium-sparing diuretics.
A client who is taking hydrochlorothiazide is experiencing significant lightheadedness and dizziness. What should the nurse instruct the client to do?
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A. “Stop taking the hydrochlorothiazide and contact your healthcare provider.”
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B. “Increase your fluid intake and avoid strenuous activity.”
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C. “Lie down with your feet elevated until the dizziness subsides.”
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D. “Take an over-the-counter medication for motion sickness.”
C. “Lie down with your feet elevated until the dizziness subsides.”
Rationale:
The symptoms suggest possible orthostatic hypotension, a common side effect of hydrochlorothiazide. Lying down with feet elevated promotes blood flow to the brain, relieving dizziness.
Option A is not the first action to take, especially for a common side effect.
Option B might help prevent dehydration but doesn’t address immediate symptoms.
Option D is not appropriate for orthostatic hypotension.
What is the primary mechanism by which most diuretics promote urine production?
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A. Stimulating renal prostaglandin synthesis.
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B. Blocking the action of aldosterone in the distal nephron.
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C. Increasing the glomerular filtration rate (GFR).
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D. Blocking sodium and chloride reabsorption in the nephron.
D. Blocking sodium and chloride reabsorption in the nephron.
Rationale:
Most diuretics work by blocking sodium and chloride reabsorption in various parts of the nephron. This disrupts the osmotic balance, leading to increased water excretion in the urine.
Option A describes a specific mechanism for loop diuretics.
Option B is the mechanism for spironolactone.
Option C is not the primary mechanism; diuretics don’t directly increase GFR.
The nurse is caring for a client receiving furosemide and gentamicin. What assessment is for the nurse to perform?
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A. Monitor the client’s blood glucose levels.
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B. Assess the client’s hearing regularly.
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C. Check the client’s blood pressure frequently.
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D. Monitor the client’s urine output for color changes
B. Assess the client’s hearing regularly.
Rationale:
Both furosemide (a loop diuretic) and gentamicin (an aminoglycoside antibiotic) are ototoxic drugs. Administering them together increases the risk of hearing impairment, requiring careful monitoring.
Option A is a consideration for furosemide but not as crucial as hearing assessment.
Option C is important for furosemide but not directly related to the interaction with gentamicin.
Option D is not a significant concern for this medication combination.
Which of the following clients is at for developing hypokalemia?
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A. A client taking a potassium-sparing diuretic
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B. A client with chronic kidney disease
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C. A client receiving intravenous fluids
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D. A client taking a high-ceiling loop diuretic
D. A client taking a high-ceiling loop diuretic
Rationale:
High-ceiling loop diuretics, such as furosemide, are potent diuretics that cause significant potassium loss through the urine. Clients taking these medications are at high risk for developing hypokalemia.
Option A is unlikely, as potassium-sparing diuretics reduce potassium loss.
Options B and C are not necessarily associated with hypokalemia.
The nurse is caring for a client with severe heart failure who is prescribed spironolactone. The client’s most recent serum potassium level is 6.2 mEq/L. What is the nurse’s ?
●
A. Administer the prescribed dose of spironolactone.
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B. Check the client’s urine output.
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C. Notify the healthcare provider.
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D. Encourage the client to increase fluid intake.
C. Notify the healthcare provider.
Rationale:
A potassium level of 6.2 mEq/L indicates hyperkalemia, a potentially serious adverse effect of spironolactone. The priority action is to notify the healthcare provider who can assess the situation and adjust the medication regimen or order further interventions.
Option A is contraindicated, as administering more spironolactone would worsen the hyperkalemia.
Option B is important for monitoring fluid status, but not the priority in this situation.
Option D is generally helpful, but not specific to hyperkalemia management.
A client with cirrhosis and ascites is prescribed spironolactone. What food should the nurse instruct the client to avoid?
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A. Bananas
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B. Apples
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C. Chicken
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D. Rice
A. Bananas
Rationale:
Bananas are high in potassium. Clients taking spironolactone, a potassium-sparing diuretic, should avoid high-potassium foods to prevent hyperkalemia.
Options B, C, and D are not high in potassium.
What is a key nursing consideration when administering mannitol intravenously?
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A. Administer the medication undiluted via IV push.
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B. Use a filter needle and in-line filter during administration.
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C. Monitor the client’s blood pressure every 2 hours.
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D. Encourage the client to restrict fluid intake.
B. Use a filter needle and in-line filter during administration.
Rationale:
Mannitol can crystallize in solution, potentially blocking IV lines and causing harm if infused. Using a filter needle when drawing up the medication and an in-line filter during administration prevents crystals from entering the bloodstream.
Option A is incorrect; mannitol is not administered as an IV push.
Option C is important, but not as specific to mannitol administration as using filters.
Option D is not appropriate; clients usually need adequate fluid intake, especially when receiving diuretics.
A client has been prescribed furosemide. What instruction should the nurse include in the client’s teaching to address the risk of postural hypotension?
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A. “Avoid consuming alcohol while taking this medication.”
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B. “Change positions slowly when getting up from a lying or sitting position.”
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C. “Take the medication in the morning to prevent sleep disturbances.”
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D. “Monitor your blood sugar levels carefully while taking this medication.”
B. “Change positions slowly when getting up from a lying or sitting position.”
Rationale:
Postural hypotension is a common side effect of furosemide. Instructing the client to change positions slowly helps prevent a sudden drop in blood pressure and reduce the risk of falls.
Option A is a general precaution for many medications but not specific to postural hypotension.
Option C addresses nocturia, not postural hypotension.
Option D addresses hyperglycemia, which can occur but is not directly related to postural hypotension.
What electrolyte imbalance is to occur in a client receiving hydrochlorothiazide?
●
A. Hypernatremia
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B. Hypokalemia
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C. Hypercalcemia
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D. Hypomagnesemia
B. Hypokalemia
Rationale:
Hydrochlorothiazide, a thiazide diuretic, increases potassium excretion in the urine, leading to hypokalemia.
Option A is less likely, as diuretics generally lead to hyponatremia.
Option C is possible, as thiazides promote calcium reabsorption.
Option D is also possible, as thiazides can increase magnesium excretion, but hypokalemia is the most common electrolyte imbalance
What is the expected outcome of administering mannitol to a client with increased intracranial pressure (ICP)?
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A. Increased urine output and decreased serum osmolality
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B. Decreased urine output and resolution of headache
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C. Increased ICP and improved level of consciousness
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D. Decreased ICP and increased urine output
D. Decreased ICP and increased urine output
Rationale:
Mannitol, an osmotic diuretic, draws fluid from the brain into the bloodstream, reducing ICP and increasing urine output.
Option A is partially correct; urine output would increase, but serum osmolality would also increase.
Option B is incorrect; urine output should increase, and a headache might not resolve immediately.
Option C is incorrect; the goal is to decrease ICP.
The nurse is caring for a client who has been prescribed triamterene. What electrolyte abnormality should the nurse anticipate as a potential side effect of this medication?
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A. Hypokalemia
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B. Hyponatremia
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C. Hyperkalemia
●
D. Hypercalcemia
C. Hyperkalemia
Rationale:
Triamterene is a potassium-sparing diuretic. Its primary side effect is hyperkalemia due to reduced potassium excretion.
Option A is incorrect, as potassium-sparing diuretics conserve potassium.
Option B is possible, but less common than hyperkalemia.
Option D is associated with thiazide diuretics, not triamterene.
The nurse is teaching a client with heart failure about the importance of daily weights. What statement by the client indicates understanding of this teaching?
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A. “Weighing myself daily will help me to track my fluid intake.”
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B. “Sudden weight gain can be a sign that my heart failure is getting worse.”
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C. “I should weigh myself after I eat breakfast every morning.”
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D. “If I gain weight, it means that I’m retaining potassium.”
B. “Sudden weight gain can be a sign that my heart failure is getting worse.”
Rationale:
Daily weights are a sensitive indicator of fluid retention, which can signal worsening heart failure.
Option A is partially correct, but weight reflects overall fluid balance, not just intake.
Option C is incorrect; weight should be taken at the same time each day, ideally before breakfast and after voiding.
Option D is incorrect; weight gain is related to fluid retention, not potassium levels.
A nurse is caring for a client with acute kidney injury who is receiving mannitol. Which assessment finding suggests an adverse reaction to this medication?
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A. Increased serum creatinine levels
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B. Decreased urine osmolality
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C. Crackles auscultated in the lungs
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D. Metabolic alkalosis
C. Crackles auscultated in the lungs
Rationale:
Mannitol can cause fluid overload, potentially leading to pulmonary edema, manifested by crackles in the lungs.
Option A would be expected in acute kidney injury and not specifically related to mannitol.
Option B is likely with mannitol, as it dilutes urine.
Option D is not typical with mannitol; metabolic acidosis is more likely.
Which statement best describes the rationale for administering furosemide to a client with pulmonary edema?
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A. To increase cardiac contractility and improve cardiac output.
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B. To reduce fluid overload in the lungs and improve oxygenation.
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C. To correct electrolyte imbalances and prevent cardiac arrhythmias.
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D. To decrease blood pressure and reduce the workload on the heart.
B. To reduce fluid overload in the lungs and improve oxygenation.
Rationale:
Furosemide’s rapid diuretic effect helps remove excess fluid from the lungs in pulmonary edema, improving ventilation and oxygenation.
Option A is not a direct effect of furosemide.
Options C and D might occur but are secondary to the primary goal of reducing pulmonary congestion.
A client with chronic liver disease who is prescribed spironolactone is at risk for what electrolyte imbalance?
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A. Hyponatremia
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B. Hypokalemia
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C. Hyperkalemia
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D. Hypernatremia
C. Hyperkalemia
Rationale:
Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia, especially in clients with compromised liver function who might have difficulty excreting potassium.
Options A and B are less likely with spironolactone.
Option D is generally unlikely with diuretic therapy.
The nurse is caring for a client taking hydrochlorothiazide for hypertension. What finding should the nurse report to the healthcare provider?
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A. Blood pressure of 130/80 mm Hg
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B. Potassium level of 3.1 mEq/L
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C. Urine output of 400 mL over 4 hours
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D. Weight loss of 1 pound
B. Potassium level of 3.1 mEq/L
Rationale:
A potassium level of 3.1 mEq/L indicates hypokalemia, a potential adverse effect of hydrochlorothiazide that requires attention.
Option A is a desirable outcome for hypertension treatment.
Option C is a normal urine output.
Option D is expected with diuretic therapy.
Which of the following statements about mannitol is accurate?
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A. Mannitol is administered orally for the treatment of edema.
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B. Mannitol is contraindicated in clients with elevated intracranial pressure.
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C. Mannitol is often prescribed for long-term management of hypertension.
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D. Mannitol must be administered intravenously.
D. Mannitol must be administered intravenously.
Rationale:
Mannitol is an osmotic diuretic that cannot be absorbed orally and therefore must be administered intravenously.
Option A is incorrect.
Option B is incorrect; mannitol is used to reduce elevated intracranial pressure.
Option C is incorrect; mannitol is used for acute conditions, not long-term management of hypertension.
