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A nurse is monitoring a client who is taking spironolactone for the treatment of hypertension. Which findings denote adverse effects of the medication? Select all that apply. ֎ -:- Tall T waves Prolonged PR interval Hyperactive bowel sounds Rationale: Spironolactone is a potassium-sparing ...

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  • 27 août 2024
  • 55
  • 2024/2025
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Excellence is key | 2024/2025 ~Page |1



Focus on Adult Health Exam Questions &
100% Correct Answers- Latest Test |
Graded A+ | Passed
A nurse is monitoring a client who is taking spironolactone for the treatment of

hypertension. Which findings denote adverse effects of the medication? Select all that

apply.


֎ -:- Tall T waves

Prolonged PR interval


Hyperactive bowel sounds


Rationale: Spironolactone is a potassium-sparing diuretic. Potassium-sparing diuretics can

cause hyperkalemia. Cardiovascular manifestations of hyperkalemia include tall T waves,

widened QRS complexes, prolonged PR intervals, and flat P waves. Other cardiovascular

manifestations include an irregular heart rate, decreased blood pressure, and ectopic

heartbeats. Muscle twitches occur in hyperkalemia. Hyperactive bowel sounds and diarrhea

also occur in hyperkalemia. Constipation, hyporeflexia, and shallow respirations are signs of

hypokalemia.




A nurse is providing dietary instructions to a client with chronic obstructive pulmonary

disease (COPD) who is experiencing a loss of appetite and complains of feeling "too full to

eat." What does the nurse encourage the client to do? Select all that apply.


֎ -:- Avoid drinking fluids before and during meals

Select foods that are easy to chew and are not gas forming



26/08/2024 | © Copyright- This work may not be copied for profit.

, Excellence is key | 2024/2025 ~Page |2


Rationale: COPD is a progressive and irreversible condition characterized by diminished

inspiratory and expiratory capacity of the lungs. Instruct the client who complains of feeling

too full to eat, to avoid drinking fluids before and during the meal. Dry foods such as

crackers stimulate coughing; foods such as milk and chocolate may increase the thickness

of saliva and secretions. Cheese is constipating and should also be avoided by the client.

The nurse should also teach the client about foods that are easy to chew and do not

encourage the formation of gas; for this reason, broccoli, which is a gas-forming food,

should be avoided.




A tuberculin skin test (TST) is administered to a client with a diagnosis of HIV infection.

Forty-eight hours after administration, the nurse checks the test site (see image).


֎ -:- Positive

Rationale: The tuberculin, or TST, test is a reliable determinant of tuberculosis (TB)

infection. A reaction measuring 5 mm or more in diameter is considered positive in a client

with HIV infection. A reaction measuring 10 mm or more in diameter is considered positive

in a non-immunosuppressed client. In this instance, the area of induration measures 9 mm,

indicating a positive reaction. A positive reaction does not mean that active disease is

present, but it does indicate exposure to TB or the presence of inactive (dormant) disease.




A nurse is interpreting a central venous pressure (CVP) reading from a client in whom right

ventricular failure has been diagnosed. From this diagnosis, the nurse would expect that the

most likely result is a pressure of




26/08/2024 | © Copyright- This work may not be copied for profit.

, Excellence is key | 2024/2025 ~Page |3


֎ -:- 14 cm H2O

Rationale: CVP measurements are used to monitor blood volume and the adequacy of

venous return to the heart. The CVP measures pressures from the right atrium or central

veins. The normal CVP is 7 to 12 cm H2O. An increased CVP reading may indicate right

ventricular failure. A low CVP reading may indicate hypovolemia. A reading of 4 cm H2O is

low. Readings of 8 and 11 cm H2O are normal. A reading of 14 cm H2O is increased.




A nurse is caring for a client who has just undergone thyroidectomy. Which technique is the

best way for the nurse to assess the surgical site for bleeding?


֎ -:- Checking for moisture on the back of the dressing over the client's neck

and shoulders

Rationale: Thyroid surgery may be complicated by hemorrhage, respiratory distress,

parathyroid gland injury (resulting in hypocalcemia and tetany), damage to the laryngeal

nerves, and thyroid storm. Hemorrhage is most likely during the 24 hours after surgery. If

the client is bleeding after surgery, gravity will cause the blood to seep down the sides of

the dressing and drain onto the underlying bed linens even as the top of the dressing

remains clean and dry. Asking the client whether the dressing feels wet and replacing the

dry sterile dressing every 2 hours are not the best actions. Replacing the dressing frequently

when it is not warranted could also increase the risk of infection.




26/08/2024 | © Copyright- This work may not be copied for profit.

, Excellence is key | 2024/2025 ~Page |4


A client who sustained a major burn injury is beginning to take an oral diet again. Which

between-meal menu selections meet the client's needs for wound healing and tissue

repair? Select all that apply.


֎ -:- Whole-milk shake and granola

Baked potato topped with cheese


Cheese and whole-wheat crackers


Rationale: To facilitate healing and meet continued high metabolic needs, the client with a

major burn should eat a diet high in calories, protein, and carbohydrates. This type of diet

also keeps the client in positive nitrogen balance. Foods such as milkshakes, granola,

cheese, and whole-wheat products are acceptable choices. Though fresh fruits and

vegetables and skim milk are high in nutrients, higher-calorie foods, including versions of

dairy products prepared with whole milk, are preferable in this situation.




A client is found to have hypoparathyroidism. Which nutritional supplement does the

nurse, teaching the client about measures to manage the disorder, tell the client to take on

a daily basis?


֎ -:- Calcium carbonate with vitamin D

Rationale: Hypoparathyroidism is an endocrine disorder in which parathyroid function is

decreased. The client with hypoparathyroidism is likely to have low calcium and high

phosphate levels and should consume a diet high in calcium but low in phosphorus.

Additionally, the generally used treatment is calcium supplementation (either as calcium

carbonate or calcium citrate) coupled with vitamin D supplementation. Vitamin C



26/08/2024 | © Copyright- This work may not be copied for profit.

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