a serum potassium level of 32 meql 32 mmoll is reported for a patient with cirrhosis who has scheduled doses of spironolactone aldactone and furosemid
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Nursing Elites

NCLEX-RN

NCLEX RN Exam Questions

1. A serum potassium level of 3.2 mEq/L (3.2 mmol/L) is reported for a patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) due. Which action should the nurse take?

Correct answer: B

Rationale: A serum potassium level of 3.2 mEq/L is low (hypokalemia), which can be concerning in a patient with cirrhosis who is already at risk for electrolyte imbalances. Spironolactone is a potassium-sparing diuretic that can help increase the patient's potassium level and correct the hypokalemia. Therefore, the appropriate action for the nurse to take in this scenario is to administer the spironolactone. Withholding the spironolactone could further lower the potassium level. Furosemide, on the other hand, is a loop diuretic that can lead to potassium loss and worsen hypokalemia; hence, it should be withheld until the nurse discusses the situation with the healthcare provider. While the healthcare provider should be informed about the low potassium value, immediate administration of spironolactone is necessary to address the hypokalemia in this patient population.

2. The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed?

Correct answer: B

Rationale: The nurse should be most concerned if 400 mL of blood is observed in the collection chamber as it may indicate the patient is at risk of developing hypovolemic shock. A large air leak in the water-seal chamber is expected initially after chest tube placement for a pneumothorax. While pain with deep inspiration should be treated, it is not as urgent as the risk of continued hemorrhage. Subcutaneous emphysema is not uncommon in a patient with pneumothorax and is usually harmless. However, a large amount of blood in the collection chamber is a more critical finding that requires immediate attention to prevent potential complications.

3. The nurse assesses a patient suspected of having meningitis. Which of the following is a common clinical manifestation of this condition?

Correct answer: A

Rationale: The correct answer is 'A high WBC count and decreased level of consciousness.' Meningitis is often caused by an infectious organism, leading to an increase in Intracranial Pressure (ICP), which can result in decreased level of consciousness. While meningitis can trigger an inflammatory response, it typically presents with an elevated white blood cell (WBC) count rather than a low WBC count. Manic activity is not a common clinical manifestation of meningitis; instead, patients may exhibit altered mental status, confusion, or lethargy.

4. What action will the nurse plan to take for a 40-year-old patient with multiple sclerosis (MS) who has urinary retention caused by a flaccid bladder?

Correct answer: B

Rationale: For a 40-year-old patient with multiple sclerosis experiencing urinary retention due to a flaccid bladder, teaching the Cred method is the appropriate action. The Cred method involves applying manual pressure over the bladder to aid in bladder emptying. Decreasing fluid intake is not the correct approach as it will not address the underlying issue of bladder emptying and may lead to dehydration and urinary tract infections. Using adult incontinence briefs only addresses the symptom of incontinence without addressing the bladder emptying problem. Assisting the patient to the commode every 2 hours does not actively address the issue of improving bladder emptying as effectively as teaching the Cred method.

5. A 25-year-old male client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication:

Correct answer: A

Rationale: The correct answer is that levothyroxine (Synthroid) should be taken in the morning. Taking it in the morning can help prevent interference with the client's sleeping pattern, as one of the side effects of levothyroxine is insomnia. Choice B is incorrect because levothyroxine is actually used to treat hypothyroidism and can help increase energy levels. Choice C is incorrect as there is no specific requirement for levothyroxine to be stored in a dark container. Choice D is incorrect because levothyroxine is more likely to increase heart rate rather than decrease it.

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