a patient is taking spironolactone aldactone to control her hypertension her serum potassium level is 6 meql for this patient the nurses priority woul
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Nursing Elites

ATI RN

Fluid and Electrolytes ATI

1. A patient is taking spironolactone (Aldactone) to control her hypertension. Her serum potassium level is 6 mEq/L. For this patient, the nurse's priority would be to assess her:

Correct answer: D

Rationale: In a patient with a serum potassium level of 6 mEq/L due to spironolactone use, the nurse's priority is to assess the Electrocardiogram (ECG) results. Hyperkalemia can lead to life-threatening arrhythmias, such as ventricular fibrillation, which can be detected on an ECG. While changes in neuromuscular function, bowel sounds, and respiratory rate can occur with hyperkalemia, the most critical assessment related to the patient's condition would be monitoring the ECG for signs of cardiac complications.

2. A nurse assesses a client who is prescribed furosemide (Lasix) for hypertension. For which acid-base imbalance should the nurse assess to prevent complications of this therapy?

Correct answer: D

Rationale:

3. A nurse is taking care of a 65-year-old female patient in a medical-surgical unit who is in renal failure; during the assessment, the patient complains of tingling in her lips and fingers. When the nurse takes her blood pressure, she has a spasm in her wrist and hand. The nurse suspects:

Correct answer: B

Rationale: The patient's symptoms of tingling in the lips and fingers along with the wrist and hand spasm are indicative of tetany, a characteristic manifestation of hypocalcemia. Hypocalcemia and hypomagnesemia can present with sensations of tingling in the extremities and around the mouth. The spasm in the wrist and hand when taking blood pressure could be due to slight ischemia of the ulnar nerve, further supporting the suspicion of hypocalcemia in this patient. Hypophosphatemia, hypermagnesemia, and hyperkalemia do not typically present with these specific symptoms and manifestations.

4. The chief mechanism for maintaining fluid balance is to:

Correct answer: C

Rationale: The correct answer is C: 'adjust fluid output so it equals fluid input.' Maintaining fluid balance involves ensuring that the amount of fluid lost through processes like urination, sweating, and respiration equals the amount of fluid taken in. This ensures that the body stays properly hydrated. Choices A, B, and D are incorrect because they do not focus on the balance between fluid input and output, which is crucial for maintaining proper fluid balance. By adjusting fluid output to equal fluid input, the body can regulate hydration levels effectively, preventing dehydration or overhydration.

5. A patient has questioned the nurses administration of IV normal saline, asking whether sterile water would be a more appropriate choice than saltwater. Under what circumstances would the nurse administer electrolyte-free water intravenously?

Correct answer: A

Rationale:

Similar Questions

A client with a serum potassium of 7.5 mEq/L and cardiovascular changes needs immediate intervention. Which prescription should the nurse implement first?
You are caring for a patient with a secondary diagnosis of hypermagnesemia. What assessment finding would be most consistent with this diagnosis?
What would be the best initial nursing action prior to inserting an IV?
Which mineral is important in hemoglobin production?
Which organ has the greatest effect on fluid output?

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