A client with congestive heart failure is prescribed spironolactone, a potassium-sparing diuretic. The nurse should instruct the client to:

Limit fluid intake to prevent fluid overload.

Avoid foods high in potassium while on this medication.

Take the medication in the morning to promote sleep.

Monitor blood pressure daily and adjust the dose accordingly.

Answer and Explanation

The Correct Answer is B

A) This choice is incorrect because limiting fluid intake is not specific to the administration of spironolactone. Fluid intake may need to be adjusted based on the client's overall fluid balance and congestive heart failure status, but it is not a direct instruction related to the medication.

B) This choice is correct. Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia (high potassium levels). The client should avoid foods high in potassium to help prevent potassium overload and potential adverse effects.

C) This choice is incorrect because the timing of spironolactone administration may vary depending on the client's individual response and the presence of other medications. The client should follow the prescribed schedule given by the healthcare provider.

D) This choice is incorrect because monitoring blood pressure daily and adjusting the dose accordingly is not specific to the administration of spironolactone. While blood pressure may need to be monitored regularly, dosage adjustments should only be made under the guidance of the healthcare provider.

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Correct Answer is C

Explanation

A) This choice is incorrect because ACE inhibitors should not be taken with grapefruit juice. Grapefruit juice can interfere with the metabolism of the medication, leading to increased levels and potential side effects.

B) This choice is incorrect because the client should not adjust the dose of the ACE inhibitor without consulting their healthcare provider. Blood pressure should be monitored, but any dosage adjustments should be made by the healthcare provider based on the client's response to the medication.

C) This choice is correct. ACE inhibitors can cause a side effect of a persistent dry cough, and in some cases, difficulty breathing. The client should promptly report these symptoms to their healthcare provider for evaluation and possible adjustment of the medication regimen.

D) This choice is incorrect because while ACE inhibitors can increase potassium levels, avoiding foods high in potassium is not necessary unless specifically directed by the healthcare provider. The client should follow a balanced diet and inform the healthcare provider of any changes in their dietary habits.

A. Reassure the client that these symptoms are normal with CHF. B. Encourage the client to increase fluid intake to prevent dehydration. C. Notify the healthcare provider about the client's symptoms. D. Administer a diuretic to reduce fluid retention.

Correct Answer is C

Explanation

A) This choice is incorrect because sudden weight gain, shortness of breath, and ankle swelling are not normal with CHF and may indicate worsening of the condition. The nurse should not reassure the client but rather take appropriate action to address the symptoms.

B) This choice is incorrect because the client's symptoms suggest fluid retention, and increasing fluid intake would exacerbate the condition. The nurse should not encourage the client to increase fluid intake without consulting the healthcare provider.

C) This choice is correct. The client's sudden weight gain, shortness of breath, and ankle swelling are signs of worsening congestive heart failure. The nurse's priority action is to notify the healthcare provider immediately to address the client's worsening condition and adjust the treatment plan as needed.

D) This choice is incorrect because administering a diuretic is not within the nurse's scope of practice without a healthcare provider's order. The nurse should first notify the healthcare provider to evaluate the client's condition and determine the appropriate intervention.

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A client with congestive heart failure is prescribed spironolactone, a potassium-sparing diuretic. The nurse should instruct the client to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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