A patient with heart failure (HF) develops hyperaldosteronism and spironolactone is prescribed. Which instruction should the nurse include in the patient's plan of care?
Limit the intake of foods high in potassium.
Cover your skin before going outside.
Replace salt with a salt substitute.
Monitor skin for excessive bruising.
The Correct Answer is A
A. Limit the intake of foods high in potassium: Spironolactone is a potassium-sparing diuretic, which means it can cause potassium levels to rise. Therefore, the nurse should advise the patient to limit the intake of potassium-rich foods to avoid hyperkalemia.
B. Cover your skin before going outside: This instruction is not specifically related to the use of spironolactone. It is more relevant for medications that cause photosensitivity or skin reactions.
C. Replace salt with a salt substitute: Many salt substitutes contain potassium, which could increase the risk of hyperkalemia when taking spironolactone. Therefore, replacing salt with a potassium-containing salt substitute is not recommended.
D. Monitor skin for excessive bruising: While monitoring for bruising is important, it is more relevant for anticoagulants or medications that affect blood clotting, not specifically for spironolactone.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Mix the capsule granules with water: Lansoprazole capsules contain granules that are typically not intended to be crushed or chewed. The appropriate method for administering these granules via an NGT is to mix them with water to ensure they are delivered properly. This approach aligns with the medication’s guidelines for administration through a tube.
B. Request the pharmacist to provide tablets: While tablets might be a suitable alternative, it is not the immediate action required if the client already has capsules. The focus should be on appropriately administering the prescribed form.
C. Open the capsule to crush the granules: Crushing or opening capsules is generally not recommended unless specifically instructed by the manufacturer or pharmacist. This can alter the drug’s effectiveness and release properties.
D. Sprinkle the granules in applesauce: Lansoprazole granules are not meant to be mixed with food like applesauce. They should be mixed with water to ensure proper dissolution and administration.
Correct Answer is B
Explanation
A. Expresses that they cannot get enough air to breathe: While this is concerning, it is less specific than a respiratory rate finding for opioid overdose.
B. Respiratory rate of 7 breaths/minute: This indicates severe respiratory depression, a critical sign of opioid overdose, which necessitates immediate administration of naloxone.
C. Intercostal retractions and bilateral wheezing on auscultation: These signs suggest respiratory distress but do not directly indicate an opioid overdose.
D. Pulse oximeter reading of 89% on room air: While low, this reading does not specifically indicate opioid overdose unless accompanied by respiratory depression.
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