A nurse is caring for a client who has cirrhosis of the liver and is receiving spironolactone. Which of the following findings indicates that the client is responding to the treatment?
Increased appetite
Decreased jaundice
Increased energy
Decreased ascites
The Correct Answer is D
A. Increased appetite can be a positive sign but is not a direct indicator of spironolactone’s effectiveness in treating cirrhosis-related complications.
B. Decreased jaundice is a positive sign but is not the primary indicator of spironolactone’s effectiveness. Jaundice is more directly related to liver function.
C. Increased energy can indicate overall improvement but is not specific to the effects of spironolactone.
D. Decreased ascites is a direct indicator that spironolactone is effective. Spironolactone is a diuretic used to reduce fluid accumulation in the abdomen (ascites) associated with liver cirrhosis. A reduction in ascites indicates that the medication is working as intended.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Breath sounds should be assessed first because naloxone is administered to reverse respiratory depression caused by opioid toxicity. Ensuring that the client is breathing adequately is the top priority.
B. Blood pressure is important to monitor, but it is not the immediate priority after administering naloxone. Respiratory status takes precedence.
C. Heart rate is also important to monitor, but it is secondary to ensuring adequate respiration.
D. Pain level should be assessed, but it is not the immediate priority following naloxone administration. The primary concern is the client’s respiratory status.
Correct Answer is B
Explanation
A. Fever can be a sign of infection or other conditions but is not directly related to warfarin therapy. It should be monitored but is not the priority in this context.
B. Melena, or black tarry stools, indicates gastrointestinal bleeding, which is a serious and potentially life-threatening complication of warfarin therapy. This finding should be reported to the provider immediately.
C. Abdominal cramping can be caused by various conditions and is not specifically related to warfarin therapy. It should be assessed but is not the priority.
D. Hair loss can occur with long-term use of warfarin but is not an immediate concern. It is a less critical side effect compared to bleeding complications.
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