A client with heart failure (HF) develops hyperaldosteronism and spironolactone is prescribed. Which instruction should the nurse include in the client’s plan of care?
Monitor skin for excessive bruising.
Replace salt with a salt substitute.
Cover your skin before going outside.
Limit the intake of foods high in potassium.
The Correct Answer is D
Choice A Reason:
Spironolactone is a potassium-sparing diuretic often prescribed for heart failure. While monitoring for side effects is important, excessive bruising is not a common side effect of spironolactone. Bruising might be more relevant for patients on anticoagulants or those with clotting disorders.
Choice B Reason:
Replacing salt with a salt substitute is not advisable for patients on spironolactone. Many salt substitutes contain potassium chloride, which can lead to hyperkalemia (high potassium levels) when combined with spironolactone. Hyperkalemia can cause serious cardiac issues, including arrhythmias.
Choice C Reason:
Covering the skin before going outside is not specifically related to the use of spironolactone. This advice might be more relevant for medications that cause photosensitivity, such as certain antibiotics or diuretics like hydrochlorothiazide, but not spironolactone.
Choice D Reason:
Limiting the intake of foods high in potassium is crucial for patients taking spironolactone. Spironolactone can increase potassium levels in the blood, and consuming high-potassium foods (like bananas, oranges, and potatoes) can exacerbate this effect, leading to hyperkalemia. Hyperkalemia can be dangerous and cause symptoms such as muscle weakness, fatigue, and cardiac arrhythmias.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Giving the next scheduled dose without further assessment is not advisable. An INR of 2.8 is within the therapeutic range for many conditions treated with warfarin, but it is important to ensure that the INR is stable and not trending higher, which could increase the risk of bleeding.
Choice B reason: Obtaining another blood sample might be necessary if there is suspicion of an error or if the INR is unexpectedly high or low. However, in this scenario, the INR is within the therapeutic range, so this action is not immediately necessary.
Choice C reason: Monitoring for signs of bleeding is always important for clients on warfarin, but it does not address the immediate need to communicate with the healthcare provider about the current INR level and any potential adjustments to the medication.
Choice D reason: Notifying the healthcare provider is the most appropriate action. The healthcare provider needs to be aware of the current INR level to make any necessary adjustments to the warfarin dosage and to provide further instructions on monitoring and follow-up.
Correct Answer is D
Explanation
Choice A reason: Zolpidem is primarily prescribed for the short-term treatment of insomnia. It works by enhancing the activity of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) at the GABA-A receptor, which helps to induce sleep. While improved sleep can indirectly affect other conditions, such as incontinence, decreased episodes of incontinence are not a direct outcome of zolpidem administration.
Choice B reason: Improved ability to concentrate is not a primary outcome of zolpidem treatment. Zolpidem is a sedative-hypnotic medication used to treat insomnia by helping patients fall asleep faster and stay asleep longer. While better sleep can improve overall cognitive function, the primary goal of zolpidem is to improve sleep quality, not directly enhance concentration.
Choice C reason: Exhibiting fewer emotional outbursts is not a direct effect of zolpidem. The medication is designed to treat insomnia and does not have a significant impact on emotional regulation. Emotional outbursts may be related to other underlying conditions that zolpidem does not address.
Choice D reason: The primary desired outcome of zolpidem administration is to help the patient sleep soundly through the night. Zolpidem is effective in reducing sleep latency and increasing the duration of sleep, which is particularly beneficial for older adults who may have difficulty maintaining sleep. Achieving a full night’s rest is the main indicator that zolpidem is working as intended.
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