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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A Reason:

Use a straw to ingest: Ferrous sulfate elixir can cause staining of the teeth. Using a straw helps to minimize contact with the teeth, thereby reducing the risk of staining. This method ensures that the medication is ingested directly into the throat, bypassing the teeth.

Choice B Reason:

Swallow undiluted: Swallowing ferrous sulfate elixir undiluted is not recommended because it can cause gastrointestinal irritation. Diluting the elixir in water or juice can help to minimize this irritation and improve absorption.

Choice C Reason:

Mix with an antacid: Mixing ferrous sulfate with an antacid is not advisable because antacids can interfere with the absorption of iron. Iron is best absorbed in an acidic environment, and antacids neutralize stomach acid, thereby reducing iron absorption.

Choice D Reason:

Take with a glass of milk: Taking ferrous sulfate with milk is not recommended because calcium in milk can inhibit the absorption of iron. It is best to take iron supplements on an empty stomach or with a source of vitamin C, such as orange juice, to enhance absorption

A. Give the next scheduled dose. B. Obtain another blood sample. C. Monitor for signs of bleeding. D. Notify the healthcare provider.

Correct Answer is D

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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