A client in an acute mental health facility is experiencing withdrawal from Opioid use and has a new prescription for Clonidine. Which of the following actions should the nurse identify as the priority?

Correct Answer: D

Rationale: In this scenario, the priority action for the nurse is to obtain baseline vital signs. This step is crucial in assessing the client's current physiological status and establishing a reference point for monitoring the effects of Clonidine. Administering the medication, providing ice chips, and educating the client are important tasks but assessing the client's vital signs takes precedence to ensure the client's safety and well-being during withdrawal management.

Correct Answer: C

Rationale: The correct answer is C because Warfarin interacts with vitamin K, found in green leafy vegetables, not potassium. The client should avoid consuming large amounts of foods high in vitamin K to maintain the effectiveness of Warfarin therapy. Increasing potassium intake is not a concern related to Warfarin therapy, so this statement indicates a need for further teaching.

Correct Answer: B

Rationale: Spironolactone is a potassium-sparing diuretic, meaning it can cause potassium retention, leading to elevated potassium levels. A potassium level of 5.2 mEq/L is above the normal range (3.5-5.0 mEq/L) and indicates hyperkalemia, which can be a serious condition. Therefore, this finding should be promptly reported to the healthcare provider for further evaluation and management to prevent potential complications.

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.