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: The correct answer is D) Place the patient in a high Fowler's position with the legs horizontal. This intervention is appropriate because positioning the patient in high Fowler's position helps to improve oxygenation by reducing pressure on the diaphragm, allowing for better lung expansion, and facilitating easier breathing. Placing the legs horizontally also promotes venous return, reducing preload on the heart and improving cardiac output. Option A) to assist the patient to cough and deep breath every 2 hours is not the most appropriate intervention for impaired gas exchange in this scenario. While coughing and deep breathing can help with lung expansion, it may not directly address the underlying issues of increased preload and mechanical failure contributing to the gas exchange problem. Option B) to assess intake and output every 8 hours and weigh daily is important for overall patient assessment and monitoring but does not directly address the immediate need for improving gas exchange in a patient with heart failure experiencing severe dyspnea and hypoxia. Option C) to encourage alternating rest and activity to reduce cardiac workload is a good general nursing intervention for patients with heart failure, but in this specific case of impaired gas exchange, the priority is to address the immediate respiratory distress and oxygenation issues. Educationally, understanding the rationale behind positioning interventions for patients with heart failure is crucial for nursing practice. Being able to connect the pathophysiology of heart failure to appropriate nursing interventions, like positioning, can significantly impact patient outcomes and quality of care.