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 D
Explanation
Metoclopramide is a medication used to treat nausea and vomiting, including those caused by chemotherapy. However, it has a potential adverse effect of causing extrapyramidal symptoms (EPS), which are involuntary movements of the body, such as muscle spasms, twitching, or restlessness. These symptoms can be distressing for patients and can interfere with their quality of life. EPS can be a sign of tardive dyskinesia, a serious and irreversible neurological disorder.
Therefore, it is essential for the nurse to monitor the client for any signs of EPS and report them immediately to the healthcare provider to prevent further complications. Unusual irritability, diarrhea, and nausea are also potential adverse effects of metoclopramide, but they are not as concerning as EPS.
Correct Answer is D
Explanation
Atorvastatin is a medication used to lower cholesterol levels in the blood. One of its side effects is muscle damage, which can result in an increase in serum creatine phosphokinase (CK) levels. Creatine phosphokinase is an enzyme found in muscles, and when muscles are damaged, CK is released into the bloodstream. Therefore, an increased serum CK level indicates muscle damage, and the nurse should assess the client for muscle tenderness or weakness, which are symptoms of this side effect. Nausea and vomiting, excessive bruising, and peripheral edema are not typically associated with atorvastatin use.
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