A nurse is collecting data from a client who is taking aspirin.
Which of the following findings should the nurse report to the provider?
Headache.
Rhinitis.
Hct 43%.
BP 120/70 mm Hg.
The Correct Answer is B
Choice A rationale:
While headache can be a side effect of aspirin, it’s usually not severe enough to warrant reporting to the provider unless it’s persistent or severe.
Choice B rationale:
Rhinitis, or inflammation of the mucous membrane of the nose, can be an allergic reaction to aspirin and should be reported to the provider.
Choice C rationale:
Hematocrit (Hct) level of 43% is within the normal range for both men (38.8–50.0 %) and women (34.9–44.5 %), so this finding would not need to be reported.
Choice D rationale:
A blood pressure reading of 120/70 mm Hg is within the normal range and would not need to be reported.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Dissolving the medication in 30 mL of water is the correct action. This ensures that the medication is in a suitable form for administration via an NG tube and helps prevent the tube from becoming blocked.
Choice B rationale:
Maintaining the client in the supine position during medication administration is not recommended. This position increases the risk of aspiration. Instead, the client should be in an upright position during medication administration and for at least 30 minutes afterward.
Choice C rationale:
Adding the medication to the enteral feeding formula is not recommended. This can alter the effectiveness of the medication and can also clog the feeding tube.
Choice D rationale:
Flushing the tube with 5 mL of water after administering the medication is not enough. The tube should be flushed with at least 15-30 mL of water before and after medication administration to ensure that the entire dose has been administered and to prevent clogging of the tube.
Correct Answer is B
Explanation
Choice A rationale:
Hypernatremia (high sodium levels) is not a common side effect of spironolactone. Spironolactone is a potassium-sparing diuretic and does not typically affect sodium levels.
Choice B rationale:
Hyperkalemia (high potassium levels) is a potential adverse effect of spironolactone. As a potassium-sparing diuretic, spironolactone can cause an increase in serum potassium levels.
Choice C rationale:
Hypophosphatemia (low phosphate levels) is not typically associated with spironolactone use.
Choice D rationale:
Hypocalcemia (low calcium levels) is also not a common side effect of spironolactone.
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