A patient is receiving spironolactone for the treatment of heart failure. Which of the following patient findings would the nurse need to assess further?
1. sodium of 150 meq/L
2. albumin level of 2.8 g/dl
3. potassium level of 5.5 meq/L
4. blood urea nitrogen (BUN) of 20 mg/dl
3
Rationale: Spironolactone, an aldosterone antagonist, causes potassium retention. The normal potassium level is 3.5 to 5.0 mEq/L. The other laboratory values are also elevated and would need additional assessment once the potassium level has been addressed.
You might also like to view...
A new nurse is admitting a patient with a history of emphysema. The new nurse's preceptor is going over the patient's past lab reports with the new nurse
The nurse takes note that the patient's PaCO2 has been between 56 and 64mm Hg for several months. The preceptor asks the new nurse why they will be cautious administering oxygen. What is the new nurse's best response? A) The patient's calcium will rise dramatically due to pituitary stimulation. B) The oxygen will increase the patient's intracranial pressure and create confusion. C) The oxygen may cause the patient to hyperventilate and become acidotic. D) Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia.
A confused patient is restless and continues to try to remove his oxygen and urinary catheter. What is the priority nursing diagnosis and intervention to implement for this patient?
a. Risk for injury: Prevent harm to patient, use restraints if alternatives fail. b. Deficient knowledge: Explain the purpose of oxygen therapy and the urinary catheter. c. Disturbed body image: Encourage patient to express concerns about body. d. Caregiver role strain: Identify resources to assist with care.
The nurse is supervising a student nurse who is working with a 14-year-old patient who delivered her first child yesterday. Which statement indicates that the nursing student understands the particular needs of an adolescent patient?
1. "This patient will need less teaching, because she will have gotten the right information in school." 2. "Because of her age, this patient will require less frequent fundal checks to assess for postpartal hemorrhage." 3. "Because of her age, this patient will probably need extra teaching about the terminology for her anatomy." 4. "This patient will need to have her grandmother provide day care and help raise the baby."
The nurse is preparing to change the dressing on a client's postoperative wound. Place in order the steps the nurse should perform when removing the soiled dressing
1. Assess the location, type, and odor of wound drainage. 2. Remove the outer dressing. 3. Discard the under dressing in a moisture-proof bag, and remove and discard gloves. 4. Remove the under dressing. 5. Apply clean gloves. 6. Place the soiled dressing in a moisture-proof bag.