A nurse is reviewing the laboratory findings of a client who has liver failure with ascites. The client takes spironolactone. Which of the following findings is an adverse effect of themedication?

Serum chloride 99 mEq/L

Serum calcium 10.5 mg/dL

Serum potassium 5.2

Serum sodium 140 mEq/L.

Answer and Explanation

The Correct Answer is C

a. Serum chloride 99 mEq/L: Serum chloride within the reference range is not an adverse effect of spironolactone.

b. Serum calcium 10.5 mg/dL: Serum calcium within the reference range is not an adverse effect of spironolactone.

c. Serum potassium 5.2: Spironolactone is a potassium-sparing diuretic, and an elevated serum potassium level is an adverse effect that requires monitoring. The nurse should assess for

hyperkalemia.

d. Serum sodium 140 mEq/L: Serum sodium within the reference range is not an adverse effect of spironolactone.

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Correct Answer is A

Explanation

a. Instruct the client to place his chin to his chest and swallow: This technique helps facilitate the passage of the nasogastric tube through the pharynx and into the esophagus.

b. Withdraw the tube if the client gags during insertion: Gagging is a normal response, and

withdrawing the tube may lead to repeated attempts and discomfort for the client. Encouraging the client to swallow can help overcome the gag reflex.

c. Place the client in a supine position: The client is usually positioned in a semi-Fowler's position or upright to ease tube insertion and minimize the risk of aspiration.

d. Measure the tube for insertion from the tip of the nose to the umbilicus: The proper

measurement for nasogastric tube insertion is typically from the tip of the nose to the earlobe and then down to the xiphoid process, not the umbilicus.

A. Nausea B. Orthopnea C. Diaphoresis D. Headache E. Tachycardia

Correct Answer is ["A","C","E"]

Explanation

a. Nausea: Nausea is a common symptom of myocardial infarction and can be associated with autonomic nervous system activation.

b. Orthopnea: Orthopnea, difficulty breathing while lying down, is more commonly associated with heart failure, not necessarily myocardial infarction.

c. Diaphoresis: Profuse sweating or diaphoresis is a common manifestation of myocardial infarction due to sympathetic nervous system activation.

d. Headache: Headache is not a typical symptom of myocardial infarction. However, some individuals may experience atypical symptoms.

e. Tachycardia: Tachycardia (rapid heart rate) is a common response to myocardial infarction and can be associated with sympathetic nervous system stimulation in response to decreased cardiac output.

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A nurse is reviewing the laboratory findings of a client who has liver failure with ascites. The client takes spironolactone. Which of the following findings is an adverse effect of themedication?

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