A client with heart failure (HF) develops hyperaldosteronism and spironolactone is prescribed. Which instruction should the nurse include in the client’s plan of care?

Monitor skin for excessive bruising.

Replace salt with a salt substitute.

Cover your skin before going outside.

Limit the intake of foods high in potassium.

Answer and Explanation

The Correct Answer is D

Choice A Reason:

Spironolactone is a potassium-sparing diuretic often prescribed for heart failure. While monitoring for side effects is important, excessive bruising is not a common side effect of spironolactone. Bruising might be more relevant for patients on anticoagulants or those with clotting disorders.

Choice B Reason:

Replacing salt with a salt substitute is not advisable for patients on spironolactone. Many salt substitutes contain potassium chloride, which can lead to hyperkalemia (high potassium levels) when combined with spironolactone. Hyperkalemia can cause serious cardiac issues, including arrhythmias.

Choice C Reason:

Covering the skin before going outside is not specifically related to the use of spironolactone. This advice might be more relevant for medications that cause photosensitivity, such as certain antibiotics or diuretics like hydrochlorothiazide, but not spironolactone.

Choice D Reason:

Limiting the intake of foods high in potassium is crucial for patients taking spironolactone. Spironolactone can increase potassium levels in the blood, and consuming high-potassium foods (like bananas, oranges, and potatoes) can exacerbate this effect, leading to hyperkalemia. Hyperkalemia can be dangerous and cause symptoms such as muscle weakness, fatigue, and cardiac arrhythmias.

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Correct Answer is ["A"]

Explanation

Choice A reason:

Heart sounds: Monitoring heart sounds is crucial for evaluating the effectiveness of medications in a client with heart failure and coronary artery disease. Changes in heart sounds, such as the presence of new murmurs or gallops, can indicate worsening heart failure or other cardiac complications1. Regular assessment helps in early detection and management of potential issues.

Choice B reason:

Blood pressure: Blood pressure monitoring is essential for clients with hypertension and those taking medications like atenolol and enalapril. These medications are used to manage blood pressure and reduce the workload on the heart. Regular monitoring ensures that the medications are effectively controlling blood pressure within the target range, typically less than 130/80 mm Hg.

Choice C reason:

Bowel sounds: While assessing bowel sounds is important for overall health, it is not directly related to evaluating the effectiveness of heart failure, CAD, or hypertension medications. Bowel sounds are more relevant in gastrointestinal assessments and do not provide specific information about the effectiveness of the prescribed cardiac medications.

Choice D reason:

Daily weight: Monitoring daily weight is a key assessment for clients with heart failure. Sudden weight gain can indicate fluid retention, which is a sign of worsening heart failure. Furosemide, a diuretic, helps manage fluid balance, and daily weight monitoring helps evaluate its effectiveness in preventing fluid overload.

Choice E reason:

Range of motion: Assessing range of motion is important for overall mobility and physical health but is not directly related to evaluating the effectiveness of medications for heart failure, CAD, or hypertension. It is more relevant in musculoskeletal assessments and rehabilitation.

A. Take the medication early in the day. B. Stand and sit up slowly. C. Reduce daily fluid intake. D. Use a twice-a-week dosing schedule.

Correct Answer is B

Explanation

Choice A reason: Taking tamsulosin early in the day is not necessary. Tamsulosin should be taken approximately 30 minutes after the same meal each day to ensure consistent absorption and effectiveness1. The timing of the dose is less critical than ensuring it is taken after the same meal daily.

Choice B reason: Tamsulosin can cause orthostatic hypotension, which is a sudden drop in blood pressure when standing up from a sitting or lying position. This can lead to dizziness or fainting. Therefore, it is crucial to instruct patients to stand and sit up slowly to prevent falls and injuries.

Choice C reason: Reducing daily fluid intake is not recommended for patients taking tamsulosin. Adequate hydration is important for overall health and can help manage urinary symptoms associated with BPH. There is no evidence suggesting that fluid restriction improves the effectiveness of tamsulosin.

Choice D reason: Tamsulosin should be taken daily, not on a twice-a-week dosing schedule. Consistent daily dosing is necessary to maintain stable blood levels of the medication and ensure its effectiveness in managing urinary retention due to BPH.

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A client with heart failure (HF) develops hyperaldosteronism and spironolactone is prescribed. Which instruction should the nurse include in the client’s plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older client with heart failure (HF), coronary artery disease (CAD), and hypertension (HTN) is receiving these daily prescriptions: atenolol, furosemide, and enalapril. Which assessments should the nurse include in evaluating the effectiveness of the medications? (Select all that apply.)

Correct Answer is ["A"]

Explanation

A client is receiving tamsulosin, an alpha-adrenergic blocking agent, for the management of urinary retention due to benign prostatic hyperplasia (BPH). Which instruction is most important for the nurse to provide?

Correct Answer is B

Explanation

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