The nurse is preparing to administer spironolactone (Aldactone) and furosemide (Lasix) at 0900 to a client diagnosed with ascites. Review of 0600 laboratory results shows serum sodium 130 mEq/L (136-145 mEq/L) and potassium 3.1 mEq/L (3.5-5.0 mEq/L). Which action should the nurse take first?
Request a dietary consult
Order a 2 gram sodium restriction diet
Initiate a fluid restriction
Hold the spironolactone and furosemide
The Correct Answer is D
A) Requesting a dietary consult is useful but not the most immediate action needed.
B) Ordering a 2 gram sodium restriction diet is important but not addressing the immediate issue of electrolyte imbalance.
C) Fluid restriction may be considered but not before addressing the electrolyte issues.
D) Holding the spironolactone and furosemide is the correct action, as administering these could exacerbate the existing hypokalemia and hyponatremia, increasing the risk of adverse effects.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Helps maintain muscle tone and promotes overall well-being without overstressing the body during recovery from hepatitis B.
B) Antibiotics are not effective against viruses like hepatitis B.
C) There is generally no need to restrict fluids in hepatitis B; adequate hydration supports overall health and liver function.
D) A high-fat diet is not recommended for liver disease; typically, a balanced, low-fat diet is more appropriate.
Correct Answer is A
Explanation
A) Weight loss is a common symptom of chronic pancreatitis due to malabsorption and decreased appetite.
B) Cool, clammy skin is not typically associated with chronic pancreatitis; it may indicate other conditions such as shock or hypotension.
C) Bruising on the flank is not a typical finding in chronic pancreatitis; it may suggest trauma or other underlying conditions.
D) Ascites, the accumulation of fluid in the abdominal cavity, is more commonly associated with advanced liver disease rather than chronic pancreatitis.
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