A nurse is educating a parent of an infant diagnosed with gastroesophageal reflux. Which statement from the parent shows they have understood the teaching?

Choice A rationale

Phosphate levels are not directly affected by spironolactone. Spironolactone is a potassium- sparing diuretic and does not typically affect phosphate levels.

Choice B rationale

Decreased potassium level is not typically expected in a patient taking spironolactone. Spironolactone is a potassium-sparing diuretic, meaning it can actually lead to increased potassium levels. However, in the context of liver failure and ascites, other factors may influence potassium levels.

Choice C rationale

Chloride levels are not directly affected by spironolactone. Spironolactone primarily affects the balance of potassium and sodium in the body.

Choice D rationale

Sodium levels could potentially be decreased in a patient taking spironolactone, as it can cause the body to lose sodium. However, in the context of liver failure and ascites, sodium levels are often carefully managed.

Essential

1. Monitoring respiratory rate closely: The client is breathing rapidly and appears anxious, making close monitoring crucial to ensure timely intervention and management of respiratory issues.

2. Providing reassurance and calming interventions: The client is anxious and discomforted. Providing reassurance and calming interventions is important to address their immediate emotional and psychological needs.

3. Checking electrolyte levels regularly: Given the client's symptoms and the need for ongoing monitoring, checking electrolyte levels is essential for managing their condition effectively.

Nonessential

1. Administering antiemetic medication: While helpful for managing nausea, this action is not immediately critical compared to other interventions that address more urgent needs.

Contraindicated

1. Encouraging the client to sit up without assistance: The client feels faint and is unsteady when sitting up. Encouraging them to sit up without assistance could be dangerous and may increase the risk of falls or injuries.

2. Increasing IV fluid rate: The current IV fluid rate is prescribed by the provider. Increasing it without further assessment could lead to complications and should be avoided unless directed by a healthcare provider.