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A nurse is caring for a client who has heart failure and is receiving spironolactone (Aldactone). Which of the following findings should indicate to the nurse that the client is experiencing an adverse effect of this medication? (Select all that apply)

Hyperkalemia

Hypokalemia

Gynecomastia

Menorrhagia

Impotence.

Answer and Explanation

Correct Answer : A,C,E

The correct answer is A, C, E.

Choice A reason:

Hyperkalemia is a known adverse effect of spironolactone because it is a potassium-sparing diuretic. This means it prevents the excretion of potassium, which can lead to elevated levels of potassium in the blood. Normal potassium levels range from 3.5 to 5.0 mEq/L.

Choice B reason:

Hypokalemia is unlikely with spironolactone use because, as a potassium-sparing diuretic, it typically leads to increased potassium levels, not decreased.

Choice C reason:

Gynecomastia, or enlargement of male breast tissue, is an adverse effect of spironolactone. This is likely due to its antiandrogenic effects, which can interfere with hormone levels.

Choice D reason:

Menorrhagia, or heavy menstrual bleeding, is not commonly associated with spironolactone. This medication does not typically affect menstrual volume or frequency.

Choice E reason:

Impotence can occur as an adverse effect of spironolactone due to its potential impact on sex hormones. It may cause erectile dysfunction or other issues related to sexual function.

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Correct Answer is B

Explanation

Choice B is wrong because Increased urine output.This indicates that the medication is effective in reducing the fluid overload and improving the renal perfusion in the client who has heart failure.

Choice A is wrong because decreased blood pressure is not a specific indicator of the medication’s effectiveness. Lisinopril (Zestril) is an angiotensin-converting enzyme (ACE) inhibitor that lowers blood pressure by blocking the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor.However, blood pressure can also be affected by other factors, such as dehydration, bleeding, or shock.

Choice C is wrong because increased heart rate is not a desired outcome of the medication. Lisinopril (Zestril) does not directly affect the heart rate, but it may cause reflex tachycardia as a compensatory mechanism for the reduced blood pressure.Increased heart rate can also worsen the cardiac workload and oxygen demand in the client who has heart failure.

Choice D is wrong because decreased respiratory rate is not a reliable sign of the medication’s effectiveness.Lisinopril (Zestril) may help reduce pulmonary congestion and dyspnea in the client who has heart failure, but respiratory rate can also be influenced by other factors, such as sedation, pain, or anxiety.

Normal ranges for vital signs are as follows:

• Blood pressure: 90/60 mm Hg to 120/80 mm Hg

• Heart rate: 60 to 100 beats per minute

• Respiratory rate: 12 to 20 breaths per minute

• Urine output: at least 30 mL per hour

A. Increased urine output B. Decreased blood pressure C. Increased heart rate D. Decreased respiratory rate.

Correct Answer is A

Explanation

Furosemide (Lasix) is a diuretic that helps reduce fluid overload and edema in clients with heart failure.Increased urine output indicates that the medication is effective in removing excess fluid from the body and improving cardiac function.

Choice B is wrong because Decreased blood pressure is wrong because furosemide (Lasix) does not directly lower blood pressure, although it may have a mild effect due to reduced blood volume.Decreased blood pressure may also indicate hypovolemia, dehydration, or shock, which are complications of heart failure and diuretic therapy.

Choice C is wrong because Increased heart rate is wrong because furosemide (Lasix) does not affect the heart rate, unless the client develops electrolyte imbalances or hypovolemia, which can cause tachycardia.Increased heart rate may also indicate worsening heart failure, as the heart tries to compensate for reduced cardiac output.

Choice D is wrong because Decreased respiratory rate is wrong because furosemide (Lasix) does not affect the respiratory rate, unless the client develops respiratory depression or alkalosis, which are rare side effects of the medication.Decreased respiratory rate may also indicate fatigue, sedation, or opioid overdose, which are not related to heart failure or diuretic therapy.

Normal ranges for urine output are 30 to 60 mL/hr for adults, blood pressure is 120/80 mm Hg or lower for normal and 140/90 mm Hg or higher for hypertension, heart rate is 60 to 100 beats/min for adults, and respiratory rate is 12 to 20 breaths/min for adults.

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A nurse is caring for a client who has heart failure and is receiving spironolactone (Aldactone). Which of the following findings should indicate to the nurse that the client is experiencing an adverse effect of this medication? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has heart failure and is receiving lisinopril (Zestril). Which of the following findings should indicate to the nurse that the medication is effective?

Correct Answer is B

Explanation

A nurse is caring for a client with heart failure who is receiving furosemide (Lasix). Which of the following findings should indicate to the nurse that the medication is effective?

Correct Answer is A

Explanation

A nurse is caring for a client who has heart failure and is receiving spironolactone (Aldactone). Which of the following findings should indicate to the nurse that the client is experiencing an adverse effect of this medication? (Select all that apply)

A nurse is caring for a client who has heart failure and is receiving captopril (Capoten). Which of the following statements by the client indicates an understanding of the medication?

A client who has heart failure tells the nurse, “I have been taking my furosemide as prescribed, but I still feel short of breath.” Which of the following statements should the nurse make?