The client on spironolactone (Aldactone) has a potassium level of 5.8 mEq/L. What is the nurse's priority action?

Correct Answer: A

Rationale: The correct answer is A: Hold the spironolactone and notify the healthcare provider. The priority action is to stop the medication and inform the healthcare provider because a potassium level of 5.8 mEq/L is above the normal range (3.5-5.0 mEq/L), indicating hyperkalemia. Spironolactone is a potassium-sparing diuretic that can further increase potassium levels. Continuing the medication or administering a potassium supplement would exacerbate the issue. Increasing the dose of spironolactone would be unsafe and could lead to severe complications. Therefore, holding the medication and seeking guidance from the healthcare provider is crucial in managing the client's elevated potassium level.

Correct Answer: A

Rationale: The correct answer is A: Platelet count. When administering enoxaparin for DVT prophylaxis, monitoring platelet count is crucial because enoxaparin can cause thrombocytopenia. Decreased platelet count can increase the risk of bleeding. Monitoring PT/INR and aPTT is more relevant for monitoring warfarin or heparin therapy, not enoxaparin. Hemoglobin monitoring is important for assessing anemia but not specifically related to enoxaparin administration for DVT prophylaxis.

Correct Answer: A

Rationale: The correct answer is A: Hold the spironolactone and notify the healthcare provider. Spironolactone is a potassium-sparing diuretic that can lead to hyperkalemia. With a potassium level of 6.0 mEq/L, the client is at risk for serious cardiac complications. Holding the medication and notifying the healthcare provider is the priority to prevent further increase in potassium levels. Administering a potassium supplement (B) would exacerbate the hyperkalemia. Continuing the spironolactone as ordered (C) or increasing the dose (D) would also worsen the situation.

Correct Answer: A

Rationale: The correct answer is A: Hold the beta blocker and notify the healthcare provider. A blood pressure of 88/58 mm Hg is considered hypotension, which can be a serious side effect of beta blockers. By holding the medication and notifying the healthcare provider, the nurse ensures prompt assessment and appropriate intervention. Administering the beta blocker (B) could further lower the blood pressure. Increasing the dose (C) would exacerbate the hypotension. Continuing to monitor and reassess (D) is not sufficient as immediate action is required due to the low blood pressure reading.

Correct Answer: D

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