DIURETICS – Flashcard

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CAI indications
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chemical derivatives of sulfonamide antibiotics***** 1. Adjunct drugs in the LONG-TERM MGMT of OPEN-ANGLE GLAUCOMA ***Used with miotics to lower intraocular pressure before ocular surgery in certain cases 2. Edema 3. High-altitude sickness ***Acetazolamide (Diamox) is used in the management of edema SECONDARY heart failure (HF) WHEN OTHER diuretics are not effective **CAIs are LESS POTENT diuretics than LOOP diuretics or THIAZIDES—the metabolic acidosis they induce reduces their diuretic effect in 2 to 4 days
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CAI ADVERSE EFFECTS
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**metabolic abnormalities: 1. **acidosis 2. ***hypokalemia 3. drowsiness, 4. anorexia, 5. paresthesias, 6. hematuria, 7. urticaria, 8. photosensitivity, 9. melena. 10. Glycosuria in diabetic patients
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CAI NURSING IMPLICATIONS
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**HYPOKALEMIA, an increase in digoxin toxicity may occur when they are combined with DIGOXIN. **Use with CORTICOSTEROIDS may also cause hypokalemia Carbonic anhydrase inhibitors require close assessment of sodium and potassium levels. These drugs are NOT TO BE used in patients with a history of renal or liver dysfunction.
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LOOP DIURETICS
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1. bumetanide (Bumex) 2. ethacrynic acid (Edecrin) 3. furosemide (Lasix) 4. torsemide (Demadex)
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LOOP DIURETICS INDICATIONS
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**VERY POTENT **useful when rapid diuresis is needed because of their rapid onset of action. The diuretic effect lasts at least 2 hours. *distinct ADVANTAGE OVER THIAZIDE diuretics in that their diuretic action continues even when creatinine clearance decreases below 25 mL/min.*** 1. Edema associated with HF or hepatic or renal disease 2. To control hypertension 3. To INCREASE renal EXCRETION of CALCIUM in patients with hypercalcemia 4. In cases of HF resulting from diastolic dysfunction Decreased fluid volume causes a reduction in: ! Blood pressure ! Pulmonary vascular resistance ! Systemic vascular resistance ! Central venous pressure ! Left ventricular end-diastolic pressure * Potassium and sodium depletion
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LOOP DIURETICS MOA
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ASCENDING LOOP OF HENLE. BLOCKING CHLORIDE and, secondarily, sodium resorption. They are also thought to activate renal prostaglandins, which results in dilatation of the blood vessels of the kidneys, the lungs, and the rest of the body.
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Loop Diuretics: Adverse Effects
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**major adverse effect of loop diuretics is ELECTROLYTE DISTURBANCES & DEHYDRATION ***Prolonged administration of high dosages can also result in hearing loss stemming from OTOTOXICITY *hypokalemia Central nervous system (CNS) Gastrointestinal (GI) Integumentary Hematologic Metabolic
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Loop Diuretics: Adverse Effects Central nervous system (CNS)
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Dizziness, headache, tinnitus, blurred vision
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Loop Diuretics: Adverse Effects Gastrointestinal (GI)
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Nausea, vomiting, diarrhea
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Loop Diuretics: Adverse Effects Integumentary
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Stevens-Johnson syndrome (torsemide)***
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Loop Diuretics: Adverse Effects Hematologic
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Agranulocytosis, neutropenia, thrombocytopenia
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Loop Diuretics: Adverse Effects Metabolic
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Hypokalemia, HYPERglycemia, HYPERuricemia
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Loop Diuretics: NURSING IMPLICATIONS
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**receive potassium supplements along with furosemide. ** electrolyte and fluid replacement. *exhibit both neurotoxic and nephrotoxic properties * affect certain laboratory results, increasing serum levels of uric acid, glucose, alanine aminotransferase, and aspartate aminotransferase. **Potassium supplements, ACE inhibitors, and severe renal failure are contraindications.
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Osmotic Diuretics
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1. ***mannitol (Osmitrol) 2. Urea 3. Organic acids 4. Glucose
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Osmotic Diuretics MOA
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works along the entire nephron, but primarily in the PROXIMAL TUBULE and descending limb of the loop of Henle.
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Osmotic Diuretics – INDICATIONS
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1. **excellent drug for PREVENTING KIDNEY damage during acute renal failure 2. **REDUCE INTRACRANIAL PRESSURE and CEREBRAL EDEMA resulting from head trauma. 3. Reduces excessive intraOCULAR PRESSURE 4. Treatment of patients in the early, oliguric phase of acute renal failure (ARF) 5. To promote excretion of toxic substances 6. NOT for PERIPHERAL edema
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Osmotic Diuretics: Adverse Effects
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1. Convulsions*** 2. Thrombophlebitis*** 3. Pulmonary congestion** Other less significant effects: 4. headaches 5. chest pain 6. tachycardia 7. blurred vision 8. chills 9. fever
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Osmotic Diuretics: Mannitol (Osmitrol) – NURSING IMPLICATIONS
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***Intravenous infusion only *May crystallize when exposed to low temperatures ***Use of a FILTER is required
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potassium-sparing diuretics
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1. amiloride (Midamor)* 2. spironolactone (Aldactone)*** (most commonly used) 3. triamterene (Dyrenium) AKA aldosterone-inhibiting diuretics
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potassium-sparing diuretics MOA
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-Work in collecting ducts and distal convoluted tubules – Interfere with sodium-potassium exchange -Competitively bind to aldosterone receptors -Block resorption of sodium and water usually induced by aldosterone **PREVENT POTASSIUM from being pumped into the tubule, thus preventing its secretion
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spironolactone and triamterene INDICATIONS
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1. Hyperaldosteronism 2. Hypertension 3. Reversing potassium loss caused by potassium- losing drugs** 4. Certain cases of HF *potassium-sparing diuretics
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amiloride INDICATIONS
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Treatment of HF *potassium-sparing diuretics
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Potassium-Sparing Diuretics: Adverse Effects
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-CNS -GI -Other
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Potassium-Sparing Diuretics: Adverse Effects – CNS
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Dizziness, headache
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Potassium-Sparing Diuretics: Adverse Effects – GI
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Cramps, nausea, vomiting, diarrhea
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Potassium-Sparing Diuretics: Adverse Effects – OTHER
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Urinary frequency, weakness, **HYPERkalemia
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Potassium-Sparing Diuretics: Adverse Effects – spironolactone (Aldactone)
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1. Gynecomastia 2. Amenorrhea 3. Irregular menses 4. Postmenopausal bleeding
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Potassium-Sparing Diuretics: Adverse Effects -Triamterene
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reduce folic acid levels–> cause the formation of KIDNEY STONES and urinary casts. **precipitate megaloblastic anemia.
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Potassium-Sparing Diuretics: NURSING IMPLICATIONS
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**Hyperkalemia may occur when potassium-sparing diuretics are used in COMBINATION with EACH OTHER and/or with OTHER potassium-sparing DRUGS such as ACE inhibitors.
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Thiazide diuretics
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1. hydrochlorothiazide (Esidrix, HydroDIURIL) 2. chlorothiazide (Diuril) **Chemical derivatives of sulfonamide antibiotics.
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! Thiazide-like diuretics
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1. metolazone (Mykrox, Zaroxolyn) 2. chlorthalidone (Hydone, Thalitone) 3. indapamide (Lozol)
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Thiazide and Thiazide-like Diuretics: Mechanism of Action
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1. Inhibit tubular resorption of sodium, chloride, and potassium ions 2. Action primarily in the DISTAL convoluted tubule Result: water, sodium, and chloride are excreted –Potassium is also excreted to a lesser extent ***Dilate the arterioles by direct relaxation
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Thiazide and Thiazide-like Diuretics: Drug Effects
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** Lowered peripheral vascular resistance ** Depletion of sodium and water (and potassium)
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Thiazide and Thiazide-like Diuretics: Indications
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1. Hypertension (one of the most prescribed group of drugs for this) *** 2. Edematous states 3. Idiopathic HYPERCALCIURIA 4. Diabetes INSIPIDUS 5. HF due to DIASTOLIC** DYSFUNCTION 6. Adjunct drugs in treatment of edema related to HF, HEPATIC CIRRHOSIS, or CORTICOSTERIOD or ESTROGEN therapy
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Thiazide and Thiazide-like Diuretics: Adverse Effects
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Major adverse effects relate to electrolyte and metabolic disturbances—mainly reduced potassium levels and elevated levels of calcium, lipids, glucose, and uric acid. **Headache, impotence, and decreased libido are other important adverse effects of these drugs. CNS GI GU Hematologic Integumentary Metabolic
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Thiazide and Thiazide-like Diuretics: Adverse Effects – CNS
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-Dizziness, -headache, -blurred vision**
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Thiazide and Thiazide-like Diuretics: Adverse Effects – GI
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Anorexia, nausea, vomiting, diarrhea
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Thiazide and Thiazide-like Diuretics: Adverse Effects – GU
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Impotence**
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Thiazide and Thiazide-like Diuretics: Adverse Effects – HEMATOLOGIC
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-Jaundice** -leukopenia
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Thiazide and Thiazide-like Diuretics: Adverse Effects – SKIN
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*Urticaria, *photosensitivity
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Thiazide and Thiazide-like Diuretics: Adverse Effects – METABOLIC
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1. Hypokalemia, 2. hyperglycemia,** 3. hyperuricemia, ** 4. hypochloremic alkalosis**
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Thiazide and Thiazide-like Diuretic NURSING IMPLICATIONS
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***Thiazides should NOT BE USED if creatinine clearance is LESS THAN 30 to 50 mL/min ***normal is 125 mL/min *Metolazone remains effective to a creatinine clearance of 10 mL/min **EXCESSIVE consumption of LICORICE can lead to additive hypokalemia in patients taking thiazides
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NURSING IMPLICATIONS – DIURETIC DRUGS
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*Assess baseline breath sounds, heart sounds, and neurologic status; in addition, check skin turgor, moisture levels of mucous membranes, and capillary refill, blood pressure, pulse rate, intake and output, and daily weights. *Assess and document the patient’s baseline fluid volume status and postural blood pressures before and during drug therapy because of diuretic-induced fluid volume loss. 1. take the medication in the MORNING if possible to avoid interference with sleep patterns 2. Monitor serum potassium levels during therapy 3. Teach patients to maintain proper nutritional and fluid volume status 4. Teach patients to eat more potassium-rich foods when taking any but the potassium-sparing drugs -Foods high in potassium include bananas, oranges, dates, apricots, raisins, broccoli, green beans, potatoes, meats, fish, and legumes 5. Patients taking diuretics along with a digitalis preparation should be taught to monitor for digitalis toxicity 6. Patients with DM who are taking thiazide and/or loop diuretics should be told to MONITOR BLOOD GLUCOSE and WATCH FOR ELEVATED LEVELS 7. CHANGE POSITIONS SLOWLY and to rise slowly after sitting or lying to prevent dizziness and fainting related to orthostatic hypotension 8. KEEP a LOG of their daily weight 9. Patients who have been ill with nausea, vomiting, and/or diarrhea should notify their primary care provider because fluid and electrolyte imbalances can result 10. Signs and symptoms of hypokalemia **Diuretic therapy may also precipitate cardiac irregularities or palpitations; therefore, continue to monitor heart rate and rhythm.
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Signs and symptoms of HYPOKALEMIA
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1. muscle weakness, 2. constipation, 3. irregular pulse rate, 4. overall feeling of lethargy
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ADVERSE REACTIONS to the diuretic DRUGS
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1. Metabolic alkalosis, 2. drowsiness (w/ CAIS) 3. lethargy, 4. hypokalemia, 5. tachycardia, 6. hypotension, 7. leg cramps, 8. restlessness, 9. decreased mental alertness 10. hyperkalemia (potassium-sparing diuretics).
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Which location is the area where the highest percentage of sodium and water are resorbed back into the bloodstream? A. Glomerulus B. Proximal tubule C. Ascending loop of Henle D. Distal tubule
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Correct answer: B Rationale: The proximal convoluted (twisted) tubule or, more simply, proximal tubule, anatomically follows the glomerulus and returns 60% to 70% of the sodium and water from the filtered fluid back into the bloodstream. Another 20% to 25% of sodium is resorbed into the bloodstream in the ascending loop of Henle. The remaining 5% to 10% of sodium resorption takes place in the distal convoluted tubule, often called simply the distal tubule, which anatomically follows the ascending loop of Henle. The glomerulus does not resorb sodium or water, but instead is the point of initial filtration of the blood.
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When administering a loop diuretic to a patient, it is most important for the nurse to determine if the patient is also taking which drug? A. lithium (Eskalith) B. acetaminophen (Tylenol) C. penicillin D. theophylline
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Correct answer: A Rationale: Use of loop diuretics with lithium can increase the risk of lithium toxicity. Drug interactions with loop diuretic therapy can occur with concurrent use of nonsteroidal antiinflammatory drugs (NSAIDs), and vancomycin can cause increased neuro- and ototoxicity when used with loop diuretics. There is no associated risk of drug interaction when taking acetaminophen, penicillin, or theophylline with loop diuretics.
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While preparing an infusion of mannitol (Osmitrol), the nurse notices small crystals in the IV tubing. The most appropriate action by the nurse is to A. administer the infusion slowly. B. discard the solution and obtain another bag of medication. C. obtain a filter, and then infuse the solution. D. return the fluid to the IV bag to dissolve the crystals.
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Correct answer: B Rationale: Even though a filter should always be used with this medication infusion, a solution with crystals present in the bag or tubing should never be infused. The nurse should first discard the solution and then restart the infusion with a new bag, ensuring that there is a filter on the IV line.
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A patient with a creatinine clearance of 20 mL/min is admitted to the medical surgical unit. The patient is in need of rapid diuresis. Which class of diuretic does the nurse anticipate administering? A. Potassium-sparing B. Thiazide C. Osmotic D. Loop
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Correct answer: D Rationale: The loop diuretics provide rapid diuresis because of their rapid onset of action. Loop diuretics are effective for patients with reduced kidney function (creatinine clearance below 25 mL/min).
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The patient is ordered furosemide (Lasix). Before administering furosemide, it is most important for the nurse to assess the patient for allergies to which drug class? A. Aminoglycosides B. Sulfonamides C. Macrolides D. Penicillins
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Correct answer: B Rationale: The nurse should assess patients receiving furosemide (Lasix) for cross-sensitivity to sulfonamides. Although allergy to sulfonamide antibiotics is listed as a contraindication, analysis of the literature indicates that cross-reaction with the loop diuretics is unlikely to occur. Loop diuretics are commonly given to such patients in clinical practice. The nurse should closely monitor these patients.
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Two days after admission, the nurse is reviewing laboratory results of the patient. Which is the most common electrolyte finding resulting from the administration of furosemide (Lasix)? A. Hypocalcemia B. Hypophosphatemia C. Hypokalemia D. Hypomagnesemia
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Correct answer: C Rationale: Of all of the adverse effects of furosemide (Lasix) administration, hypokalemia is of serious clinical importance. To prevent hypokalemia, patients often receive potassium supplements along with furosemide. The other electrolyte disturbances listed do not occur as a result of furosemide (Lasix) therapy.
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The patient is being discharged home with furosemide (Lasix). When providing discharge teaching, which instruction will the nurse include? A. Avoid prolonged exposure to the sun. B. Avoid foods high in potassium content. C. Stop taking the medication if you feel dizzy. D. Weigh yourself once a week and report a gain or loss of more than 1 pound.
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Correct answer: A Rationale: Patients taking furosemide (Lasix) should avoid prolonged exposure to the sun because the drug can cause photosensitivity. Although orthostatic hypotension is a possible adverse effect of the medication, patients should not stop taking the medication without consultation with their health care provider. Patients should weigh themselves once a day and report a weight gain or loss of approximately 3 pounds. Patients taking furosemide (Lasix) should be encouraged to eat foods rich in potassium.

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