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. Which problem in a client requires the most immediate intervention by the nurse?

Correct answer: B

Rationale: The correct answer is B: Increasing sharp pain related to compartment syndrome. Compartment syndrome is a serious condition where increased pressure within a muscle compartment compromises circulation and can lead to tissue damage. Immediate intervention is crucial to prevent permanent damage to muscles and nerves, including tissue necrosis and nerve injury. Choices A, C, and D do not present the same level of urgency as compartment syndrome, making them less critical for immediate intervention. Carpal tunnel syndrome, Morton's neuroma, and plantar fasciitis may cause discomfort and functional limitations but are not typically considered emergencies requiring urgent intervention like compartment syndrome.

3. A client with hepatic encephalopathy is being treated with lactulose. What is an expected outcome of this treatment?

Correct answer: A

Rationale: Lactulose is used to treat hepatic encephalopathy by reducing blood ammonia levels through promoting its excretion via the intestines. Elevated ammonia levels contribute to the development of encephalopathy symptoms, so by lowering them, the client's neurological status can improve.

4. The healthcare provider is caring for a client who has just undergone a thyroidectomy. Which assessment finding requires immediate intervention?

Correct answer: C

Rationale: Numbness and tingling around the mouth can indicate hypocalcemia, a potential complication after thyroidectomy. Hypocalcemia can occur due to inadvertent injury or removal of the parathyroid glands during the thyroidectomy, leading to decreased calcium levels. As a result, the client may experience symptoms such as numbness, tingling, muscle cramps, or spasms. Prompt intervention is necessary to prevent severe complications like tetany or seizures. Therefore, the healthcare provider should address numbness and tingling around the mouth immediately to prevent further deterioration of calcium levels and potential serious outcomes. Choices A, B, and D are not typically associated with immediate post-thyroidectomy complications and can be addressed after ensuring the client's calcium levels are stable.

5. In planning the turning schedule for a bedfast client, it is most important for the nurse to consider what assessment finding?

Correct answer: B

Rationale: A low Braden score indicates a high risk for pressure ulcers, making regular turning crucial to prevent skin breakdown.

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