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)

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.

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