A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client?
Serum potassium
Platelet count
Urine ketones
Total bilirubin
The Correct Answer is A
Rationale:
A. Serum potassium: Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia. Monitoring serum potassium is essential to detect elevated levels early and prevent cardiac complications.
B. Platelet count: Spironolactone does not significantly affect platelet production or function, so routine monitoring of platelets is not indicated for this medication.
C. Urine ketones: Ketone monitoring is relevant for clients with uncontrolled diabetes or ketosis, but it is not related to spironolactone therapy.
D. Total bilirubin: Bilirubin levels are used to assess liver function, which is not directly affected by spironolactone in most clients, so routine monitoring is not necessary unless the client has underlying hepatic disease.
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Related Questions
Correct Answer is C
Explanation
A. Clostridium difficile: C. difficile infections are typically managed within healthcare facilities and are not considered reportable to local health departments under standard public health reporting requirements.
B. Herpes simplex virus: HSV infections are common and usually not reportable to public health authorities, except in cases of neonatal herpes or unusual outbreaks, as routine cases are managed clinically.
C. Chlamydia trachomatis: Chlamydia is a sexually transmitted infection that is nationally notifiable. Reporting to the local health department is required to track incidence, prevent spread, and facilitate partner notification and treatment.
D. Human papilloma virus: HPV infections are widespread and typically not reportable because most cases are asymptomatic or self-limiting. Reporting is not required for routine surveillance or treatment purposes.
Correct Answer is D
Explanation
A. Irrigate a client's incision: Wound irrigation is a sterile procedure that requires nursing judgment and skill to prevent infection and assess wound healing. This task should not be delegated to assistive personnel.
B. Determine a client's pain level: Assessing pain requires clinical judgment to interpret subjective and objective findings and evaluate the need for interventions. This responsibility remains with the licensed nurse.
C. Insert a nasogastric tube: Insertion of a nasogastric tube is an invasive procedure that requires nursing knowledge and technical skill to ensure proper placement and prevent complications. It is not within the scope of assistive personnel.
D. Provide postmortem care: Postmortem care is a noninvasive task that involves preparing the body, performing hygiene, and maintaining dignity. It falls within the scope of practice for assistive personnel and can be safely delegated.
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