the client on spironolactone aldactone has a potassium level of 58 meql what is the nurses priority action
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Nursing Elites

ATI RN

Cardiovascular System Exam

1. The client on spironolactone (Aldactone) has a potassium level of 5.8 mEq/L. What is the nurse’s priority action?

Correct answer: A

Rationale: With a potassium level of 5.8 mEq/L, which is high, the priority action for the nurse is to hold the spironolactone. Spironolactone is a potassium-sparing diuretic that can further increase potassium levels. Therefore, it is crucial to prevent exacerbating hyperkalemia by discontinuing the medication. Notifying the healthcare provider is necessary for further guidance and potential adjustments to the treatment plan. Administering a potassium supplement (Choice B) would be contraindicated since the client already has elevated potassium levels. Continuing the spironolactone as ordered (Choice C) can worsen hyperkalemia. Increasing the dose of spironolactone (Choice D) would be unsafe and exacerbate the high potassium levels.

2. The nurse is preparing to administer a beta blocker to a client with hypertension. What is the priority assessment?

Correct answer: B

Rationale: The correct answer is to check the client's blood pressure. Before administering a beta blocker to a client with hypertension, assessing the blood pressure is crucial because beta blockers can cause hypotension, potentially leading to adverse effects. Checking the heart rate may also be important but is secondary to monitoring the blood pressure in this scenario. Respiratory rate and temperature assessments are not directly related to assessing the client's response to a beta blocker in hypertension management, making choices C and D less relevant.

3. This is the inflammation of the heart's inner lining, usually caused by an infection.

Correct answer: A

Rationale: Endocarditis is the inflammation of the inner lining of the heart's chambers and valves, usually caused by a bacterial infection. Myocarditis is the inflammation of the heart muscle, Pericarditis is the inflammation of the pericardium (the outer lining of the heart), and Valvulitis is the inflammation of the heart valves. Therefore, in this case, the correct answer is Endocarditis as it specifically refers to the inflammation of the heart's inner lining.

4. What is a condition where the heart muscle is weakened and unable to pump blood effectively, often leading to heart failure?

Correct answer: A

Rationale: Cardiomyopathy is the correct answer. In cardiomyopathy, the heart muscle becomes weak and cannot pump blood effectively, which can lead to heart failure. Myocarditis (choice B) is inflammation of the heart muscle, not specifically causing muscle weakness. Endocarditis (choice C) is an infection of the inner lining of the heart chambers and valves. Pericarditis (choice D) is inflammation of the pericardium, the outer lining of the heart.

5. What is the condition where the blood flow through the coronary arteries is reduced or blocked, leading to chest pain or heart attack?

Correct answer: A

Rationale: The correct answer is A, Coronary artery disease (CAD). CAD occurs when the coronary arteries are narrowed or blocked, reducing blood flow to the heart muscle and increasing the risk of chest pain or heart attack. Choice B, Atherosclerosis, is a condition characterized by the hardening and narrowing of arteries due to the buildup of plaque. Choices C and D, Pulmonary embolism and Pulmonary hypertension, involve issues related to the lungs and not the coronary arteries.

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