A client with heart failure (HF) develops hyperaldosteronism and spironolactone is prescribed. Which instruction should the nurse include in this patient’s plan of care?
Replace salt with a salt substitute.
Limits intake of high-potassium foods.
Cover your skin before going outside.
Monitor skin for excessive bruising.
The Correct Answer is B
Spironolactone is a potassium-sparing diuretic that works by blocking the actions of aldosterone, a hormone that can lead to potassium loss in the urine. However, in some cases, spironolactone can cause hyperkalemia (high levels of potassium in the blood), which can be dangerous for patients with heart failure. Therefore, it is important to instruct the patient to limit their intake of high-potassium foods such as bananas, oranges, tomatoes, spinach, and salt substitutes containing potassium.
Option a (Replace salt with a salt substitute) is incorrect because salt substitutes often contain potassium, which can further increase the risk of hyperkalemia.
Option c (Cover your skin before going outside) is unrelated to the use of spironolactone and hyperkalemia.
Option d (Monitor skin for excessive bruising) is not directly related to the use of spironolactone and hyperkalemia, although it is a potential side effect of other medications used to treat heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Before administering the first dose of any antibiotic, it is essential to obtain a culture and sensitivity test to identify the causative organism and determine the most effective antibiotic to use. Administering a broad- spectrum antibiotic before obtaining a culture and sensitivity test may lead to the development of antibiotic-resistant strains of bacteria, making it more difficult to treat the infection in the future.
Options a, c, and d are not as important as obtaining a culture and sensitivity test. Monitoring for signs of sodium and fluid retention, irrigation and topical antibiotic application to the wound area, and completing blood count and serum electrolytes are important, but obtaining a culture and sensitivity test is the priority.
Correct Answer is A
Explanation
The nurse should explain to the client's daughter that Rivastigmine is most effective when used early during Alzheimer's disease. Delaying the use of the medication until the symptoms are no longer manageable may result in the drug being less effective.
The nurse should emphasize the importance of following the healthcare provider's instructions for administering the medication to maximize its therapeutic effect. It is important to educate the client's daughter about the progressive nature of Alzheimer's disease and the need for ongoing monitoring and care.
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