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

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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. Which of the following might the nurse assess in a patient diagnosed with hypermagnesemia?

Correct answer: A

Rationale: The correct answer is A: Diminished deep tendon reflexes. In a patient with hypermagnesemia, the nurse would assess for diminished deep tendon reflexes. Hypermagnesemia can lead to neuromuscular depression, causing a decrease in deep tendon reflexes. Tachycardia (choice B) is more commonly associated with hypomagnesemia. Cool clammy skin (choice C) is not typically a direct symptom of hypermagnesemia. While hypermagnesemia does involve increased serum magnesium levels (choice D), assessing serum levels is a laboratory test and not a clinical assessment like checking deep tendon reflexes.

3. You are the nurse caring for a patient who is to receive IV daunorubicin, a chemotherapeutic agent. You start the infusion and check the insertion site as per protocol. During your most recent check, you note that the IV has infiltrated so you stop the infusion. What is your main concern with this infiltration?

Correct answer: A

Rationale:

4. A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse?

Correct answer: B

Rationale:

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:

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