A patient with heart failure develops hyperaldosteronism and is prescribed spironolactone.


What instructions should the nurse include in the patient’s care plan?

Choice A rationale

While reducing salt intake is generally beneficial for clients with heart failure, replacing salt with a salt substitute is not recommended for clients taking spironolactone. Many salt

substitutes contain potassium, and spironolactone can cause high potassium levels in the blood.

Choice B rationale

Covering the skin before going outside is a general recommendation for sun protection, but it is not specifically related to the use of spironolactone.

Choice C rationale

Spironolactone is a potassium-sparing diuretic, which means it can cause the body to retain potassium. Therefore, clients taking this medication should be advised to limit their intake of high-potassium foods to prevent hyperkalemia, a potentially serious condition characterized by high levels of potassium in the blood.

Choice D rationale

While it is always important to monitor for signs of bruising, this is not the most critical instruction for a client taking spironolactone. The risk of hyperkalemia is a more immediate concern.

Choice A rationale

Determining when the last dose was administered is an important step in managing a client’s pain. However, it should not be the first action taken when a client requests the largest possible dose of pain medication. The nurse first needs to assess the client’s current level of pain to determine the appropriate intervention.

Choice B rationale

Reviewing the history for past use of recreational drugs is an important part of a comprehensive pain assessment. However, it should not be the first action taken when a client requests the largest possible dose of pain medication. The nurse first needs to assess the client’s current level of pain to determine the appropriate intervention.

Choice C rationale

Asking the client to rate the current level of pain using a pain scale should be the first action the nurse takes when a client requests the largest possible dose of pain medication. Pain is subjective and can only be accurately assessed by the person experiencing it. Using a pain scale helps the nurse quantify the client’s pain and guide appropriate interventions.

Choice D rationale

Encouraging the client to use diversional thoughts to manage pain can be a helpful non- pharmacological pain management strategy. However, it should not be the first action taken when a client requests the largest possible dose of pain medication. The nurse first needs to assess the client’s current level of pain to determine the appropriate intervention.