Correct Answer: C

Rationale: A serum potassium level of 5.2 mEq/L indicates hyperkalemia. Spironolactone is a potassium-sparing diuretic that can lead to potassium retention. The nurse should notify the provider and withhold the medication to prevent further elevation of potassium levels, which can result in serious cardiac complications.

Correct Answer: B

Rationale: The correct administration of Nitroglycerin sublingual tablets involves taking one tablet at the onset of chest pain and repeating every 5 minutes for up to three doses. If the pain persists after three doses, emergency medical services should be contacted for further evaluation and management.

Correct Answer: B

Rationale: Pamidronate is given through IV infusion and can be irritating to veins. Therefore, the nurse should frequently assess the IV site for thrombophlebitis during the administration to promptly detect any potential complications related to the infusion.

Correct Answer: C

Rationale: The correct answer is C: Delirium. When IV nitroprusside is administered at high dosages, it can lead to thiocyanate toxicity, resulting in mental status changes such as delirium. Monitoring thiocyanate levels during therapy is crucial to ensure they remain below 10 mg/dL to prevent this adverse reaction.

Correct Answer: B

Rationale: Coarse tremors are a common sign of Lithium toxicity. It is important for healthcare providers to monitor for this symptom as it indicates a potential overdose of the medication. Severe hypertension, constipation, and muscle spasms are not typically associated with Lithium toxicity.