A patient with heart failure (HF) develops hyperaldosteronism and spironolactone is prescribed. Which instruction should the nurse include in the patient's plan of care?
Limit the intake of foods high in potassium.
Cover your skin before going outside.
Replace salt with a salt substitute.
Monitor skin for excessive bruising.
The Correct Answer is A
A. Limit the intake of foods high in potassium: Spironolactone is a potassium-sparing diuretic, which means it can cause potassium levels to rise. Therefore, the nurse should advise the patient to limit the intake of potassium-rich foods to avoid hyperkalemia.
B. Cover your skin before going outside: This instruction is not specifically related to the use of spironolactone. It is more relevant for medications that cause photosensitivity or skin reactions.
C. Replace salt with a salt substitute: Many salt substitutes contain potassium, which could increase the risk of hyperkalemia when taking spironolactone. Therefore, replacing salt with a potassium-containing salt substitute is not recommended.
D. Monitor skin for excessive bruising: While monitoring for bruising is important, it is more relevant for anticoagulants or medications that affect blood clotting, not specifically for spironolactone.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Administer both prescribed medications as scheduled: Given that the client's total calcium level is already elevated (14 mg/dL), administering additional calcium carbonate could exacerbate hypercalcemia. Calcitriol, a form of vitamin D, can also increase calcium levels, so administering it without addressing the high calcium level could worsen the condition.
B. Hold the calcium carbonate, but administer the calcitriol as scheduled: This option is not appropriate because calcitriol can further increase calcium levels, potentially worsening hypercalcemia. Both medications should be reviewed, and their administration should be adjusted according to the client's current calcium status.
C. Hold the calcitriol, but administer the calcium carbonate as scheduled: Holding calcitriol alone would not address the potential for further increasing calcium levels. Calcium carbonate should also be withheld since the client is already hypercalcemic.
D. Hold both medications until contacting the healthcare provider: This is the most appropriate action. The client's elevated calcium level indicates hypercalcemia, which requires careful management. The healthcare provider should be contacted to assess the situation and determine the appropriate course of action to avoid worsening hypercalcemia.
Correct Answer is A
Explanation
A. Ensure that the client eats breakfast: Regular insulin is a fast-acting insulin that typically begins to work within 30 minutes to an hour after administration, peaks around 2-3 hours, and can last for up to 6 hours. Therefore, it is crucial that the client eats a meal, such as breakfast, shortly after the insulin is administered to prevent hypoglycemia.
B. Provide a mid-afternoon snack for the client: While snacks may be necessary depending on the client's overall meal and insulin schedule, it is more critical to ensure the client eats the meal immediately following insulin administration to manage blood glucose levels.
C. Assess the client for hypoglycemia around 1500: While monitoring for hypoglycemia is important, it is more critical to ensure the client eats their meal soon after insulin administration to prevent hypoglycemia in the first place.
D. Perform a glucometer reading at 1000: A glucometer reading at 1000 might be useful for monitoring blood glucose levels but ensuring that the client eats a meal promptly is a more immediate and critical action following insulin administration.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
