Drugs used for Diuresis (Ch.29)

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Diuretics
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Drugs that act to increase the flow of urine
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Purpose of Diuretics
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To increase the net loss of water
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How is diuresis achieved?
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Acts on kidneys in different locations to enhance the excretion of sodium
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What do Methylxanthines do?
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Increase glomerular filtration
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What does Spironolactone do?
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Inhibits tubular reabsorption of sodium by inhibiting Aldosterone
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What do Thiazide/Loop Diuretics do?
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Act directly on kidney tubules to inhibit the reabsorption of Na/Cl/H2O
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What happens to Na and Cl that are not reabsorbed ?
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They are excreted into the collecting ducts then into the urteres then to the bladder, taking large volumes of water to be excreted from the body through urination
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Diuretics are used for?
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1) *Heart Failure (to removes excess na/h20 to relieve symptoms assoc. w/ pulmonary congestion and edema) 2) *Hypertension (can reduced the morbidity/mortality assoc. w/ hypertension) 3) Cerebral Edema 4) Intraoccular Pressure assoc. w/ Glaucoma 5) Ascites assoc. w/ Liver Disease 6) Hypercalcemia
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When older adults are taking diuretics what should they be monitored for?
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Hydration Status Electrolyte Balance Response to the tx
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Patient taking Digoxin is at what risk?
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At an increased for developing digitalis toxicity due to electrolyte imbalance
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What are some signs of dehydration?
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Inelastic skin turgor Sticky oral mucus membranes Shrunken/deeply furrowed tongue Crusted lips Wt loss Deteriorating vitals Soft/sunken eyeballs Weak pedal pulses Delayed capillary filling Excessive thirst High urine specific gravity No urine output Possible mental confusion
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When patient is over hydrated what lab changes will be noticed?
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Hemodilution= values appear to drop
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When patients are dehydrated what lab changes will be noticed?
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Hemoconcentration= values appear higher
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Edema
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Excessive fluid accumulation in extracellular spaces (+1)-Slight (+4)-Deep Cool Tight Shiny Pale skin Crackles in the lung sounds (Excess fluid)
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Signs and symptoms of electrolyte imbalance
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Mental Status (alertness, orientation, confusion) Muscle Strength Muscle Cramps Tremors Nausea General Apperance
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Susceptible people to Electrolyte Imbalance
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1) History of renal/cardiac disease 2) Hormonal Disorders 3) Massive Trauma 4) Burns 5) Receiving Diuretic/Steroid Tx
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Hypokalemia
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K+ levels <3.5 mEq/L Vomit Diarrhea Heavy Diuresis **All diuretics EXCEPT K-sparing can cause this
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Hyperkalemia
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K+ levels >5.5 mEq/L Excessive amounts of K supplements (IV/PO) Adverse effects of K-sparing diuretics or renal disease
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Hyponatremia
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Na levels <135 mEq/L **"Where sodium goes, water goes" Monitor for hyponatremia in patient during/after diuresis
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Hypernatremia
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Na levels >145 mEq/L When given IV fluids in excess of the fluid that has been excreted
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What are the different areas that can be recorded for output?
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Mouth Urethra Rectum Wounds Tubes (catheters) Daily output= 1200-1500mL or 30-50mL/hr **Low urinary output can be a sign of dehydration, renal failure, or cardiac disease
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Medication Considerations for Diuretics
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1) Taken Early morning-Mid Afternoon to avoid nocturia 2)Daily wt–same time, usually before breakfast **Gaining 2+ lbs in 2 days needs to be reported!!!!!
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***DO NOT ADMINISTER DIURETICS AFTER WHAT TIME
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NO LATER THAN MID AFTERNOON–TO PREVENT NOCTURIA!
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Things to remember about nutrition when taking diuretics
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Potassium Sparing: K foods/salts limited use or restricted Other Diuretics: Required to consume high K foods
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Names of Sulfonamide-Type Loop Diuretics
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Furosemide (Lasix) Torsemide (Demedex)
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MOA of Furosemide (Lasix)/Torsemide (Demedex)?
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1) Inhibits Na/Cl reabsorption in the ascending loop of Henle 2) Promotes excretion of Na, Cl, Mg, Phosphate, HCO3, Water 3) Increases Renal Blood Flow and GFR
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Uses of Furosemide (Lasix)/Torsemide (Demedex)
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1) Hypertension 2) Edema from HF, Cirrhosis of Liver, Renal Disease 3) Hypercalcemia (Furosemide ONLY!) –promotes loss of Ca in urine
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What needs to be assessed before the administration of Uses of Furosemide (Lasix)/Torsemide (Demedex)?
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Baseline VS Lung Sounds Wt Degree of Edema in Patient Lab Studies (electrolytes, renal/liver function) Mental Status Muscle Strength *Pt with DM–check blood glucose Check for Symptoms of Gout Any Reduction in Hearing
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** Patients that are allergic to Sulfonamides (sulfa) may be allergic to Sulfonamide-Type Loop Diuretics as well!!!
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Common Adverse Effects of Uses of Furosemide (Lasix)/Torsemide (Demedex)
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Oral Irritation, Dry Mouth (use h202 mouth wash) Orthostatic Hypotension
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Serious Adverse Effects of Uses of Furosemide (Lasix)/Torsemide (Demedex)
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1) GI Irritation, Abd Pain 2) Electrolyte Imbalance, Dehydration (monitor mental status-*K loss! 3) Hyperuricemia (check labs and s/s of gout) 4) Hyperglycemia (glycosuria) 5) Hypersensitivity (sulfa allergy) 6) Hearing Loss
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Drug Interactions with Uses of Furosemide (Lasix)/Torsemide (Demedex)
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1) Alcohol, Barbiturates, Narcotics= Additive Hypotension 2) Digoxin= Digitalis Toxicity (causes excessive K excretion) 3) NSAIDs= Decreases Loop Diuretic Activity 4) Steroids= Increases Risk of Hypokalemia
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Name of Non Sulfonamide Diuretics
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Ethacrynic Acid (Edecrin)
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MOA of Ethacrynic Acid (Edecrin)
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Inhibits NaCl absorption in the ascending loop of henle * Does not effect renal blood flow or glomerular filtration rate
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Use of Ethacrynic Acid (Edecrin)
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1) Edema from HF, Cirrhosis of Liver, Renal Disease, Malignancy, Pediatric Patients 2) Hypercalcemia
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Assessments that should be done prior to the administration of Ethacrynic Acid (Edecrin)
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Baseline VS Lung Sounds Wt Degree of Edema in Patient Lab Studies (electrolytes, renal/liver function) Mental Status Muscle Strength *Pt with DM–check blood glucose Check for Symptoms of Gout Any Reduction in Hearing
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Common Adverse Effects of Ethacrynic Acid (Edecrin)
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Orthostatic Hypotension
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Serious Adverse Effects of Ethacrynic Acid (Edecrin)
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1) Electrolyte Imbalance, Dehydration 2) Dizzy, Deaf, Headache 3) GI Bleeding, Diarrhea 4) Hyperglycemia
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Drug Interactions for Ethacrynic Acid (Edecrin)
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NSAIDs Digoxin Steroids
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Name of Thiazide Diuretics
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Hydrochlorothiazide (HydroDIURIL)
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MOA of Hydrochlorothiazide (HydroDIURIL)
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Blocks NaCL reabsorption from the distal tubule **NaCl that’s not reabsorbed are passed into the collecting ducts, taking molecules or water with them resulting in diuresis **Slower onset og action compared to the loop diuretics **Moderate fluid loss compared to the loss in loop diuretics
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Use of Hydrochlorothiazide (HydroDIURIL)
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HTN Edema from HF, Renal/Liver Disease, Pregnancy, PMS
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What should be assessed prior to the administration of Hydrochlorothiazide (HydroDIURIL) ?
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Baseline VS Lung Sounds Wt Degree of Edema in Patient Lab Studies (electrolytes, renal/liver function) Mental Status Muscle Strength *Pt with DM–check blood glucose Check for Symptoms of Gout Any Reduction in Hearing
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Common Adverse Effects of Hydrochlorothiazide (HydroDIURIL)
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Orthostatic Hypotension
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Serious Adverse Effects of Hydrochlorothiazide (HydroDIURIL)
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GI Irritation, N/V, Constipation Electrolyte Imbalance Dehydration Hyperuricemia Hyperglycemia Hypersensitivity
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Drug interactions with Hydrochlorothiazide (HydroDIURIL)
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NSAIDs Steroids Lithium Digoxin
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Names of the Potassium Sparing Diuretics
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Amiloride (Midamor) Spironolactone (Aldactone) Trianlterene (Dyrenium)
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MOA for Amiloride (Midamor), Spironolactone (Aldactone), Trianlterene (Dyrenium)
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Induces retention of K Excretion of Na at distal tubules
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Uses of Amiloride (Midamor), Spironolactone (Aldactone), Trianlterene (Dyrenium)
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1) *In combo with other diuretics to tx HTN 2) To relieve edema related to HF and liver disease 3) To prevent hypokalemia in patient taking loop or thiazide diuretics
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Assessments that must be made prior to the administration of Amiloride (Midamor), Spironolactone (Aldactone), Trianlterene (Dyrenium)
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Baseline VS Lung Sounds Wt Degree of Edema Present Lab Studies Mental Status *Libido (Spironolactone ONLY!)
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Common Adverse Effects of Amiloride (Midamor), Spironolactone (Aldactone), Trianlterene (Dyrenium)
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Anorexia Nausea Vomiting Flatulence Headache
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Serious Adverse Effects of Amiloride (Midamor), Spironolactone (Aldactone), Trianlterene (Dyrenium)
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1) *Electrolyte Imbalance: Hyperkalemia (K sparing) 2) Dehydration 3) Gynecomastia, Reduced Libido (Spironolactone ONLY) 4) Hypersensitivity (Triamterene ONLY)
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Drug Interactions with Amiloride (Midamor), Spironolactone (Aldactone), Trianlterene (Dyrenium)
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1) *ACEI, ARBs, Aldosterone Blockers= Increase risk for hyperkalemia 2) *K Supplements/ K Salts= Increased risk for hyperkalemia 3) NSAIDs= diminished diuretic effect
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Names of The Combination Diuretic Products
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Spironolactone/Hydrochlorothiazide (Aldactazide) Triamterene/Hydrochlorothiazide (Dyazide, Maxzide) Amiloride/Hydrochlorothiazide (Moduretic)
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Goal of The Combination Diuretic Products
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To promote diuresis and antihypertenisive effect through different mechanisms of action while maintaining normal serum potassium levels
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Common Adverse Effects of The Combination Diuretic Products
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Hyperkalemia Hyponatremia
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A patient has been placed on a loop diuretic to reduce the fluid that has been accumulating in the lungs. A statement made by the patient that would indicate further teaching is?
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I’ll be sure to take my medication with supper
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A patient with a history of heart failure is prescribed Furosemide (Lasix). Several days after the aggressive diuretic therapy started, the patient began to exhibit confusion, tremors, muscle cramps, and nausea. What does the nurse suspect?
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Hypokalemia
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A patient reviewing Furosemide (Lasix) for a month reports experiencing pain in the toes. The patient states it has been years since having that type of pain. What does the nurse suspect?
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Gout
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Which is a common finding with combination diuretic products?
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They increase the risk of hyperkalemia and hyponatremia
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The nurse is reviewing what is meant by hyperkalemia. What is a correct statement?
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Occurs most frequently with potassium-sparing diuretics
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Which diagnostic tests would be ordered to determine renal function?
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Serum Creatinine BUN
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Which condition may thiazide diuretic therapy cause?
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Hyperuricemia
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NSAIDs taken concurrently with certain diuretics (Bumetanide, Furosemide, and Ethacrynic Acid) can have which result?
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Decreased Diuresis
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Potassium supplements and salt substitues should not be give with which class of diuretic?
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Potassium-Sparing
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What is the main purpose of using diuretics for treating heart failure?
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Relieve symptoms associated with pulmonary congestion and edema
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Which are methods for assessing for hydration?
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Skin turgor Oral mucus membranes Vital signs Weight changes
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Why are diuretics usually not administered after mid noon?
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To prevent nocturia
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When assessing a patient who is overhydrated, which assessment finding does the nurse expect to see?
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Neck Vein Engorgement
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What are the classic signs of dehydration that the nurse will assess for and report?
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Shrunken or deeply furrowed tongue Delayed capillary filling Soft or sunken eyeballs Weak pedal pulses
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A patient who has received IV fluids in excess of fluids excreted is likely to develop which electrolyte imbalance?
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Hypernatremia
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When taking a history of a patient with fluid volume excess, the nurse should ask the patient questions that contribute to fluid volume excess such as?
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Dysrhythmias Heart Failure MI
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Patients with which conditions are prone to developing fluid volume excess?
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Hypertension Heart Failure Renal Disease (renal failure) Ascites
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The nurse should be aware of factor that may predispose a patient to the development of fluid volume excess such as?
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Immobility Corticosteroid Agents Hypertension Pregnancy
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What lab test should be performed to determine if the patient has impaired kidney function?
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BUN Serum creatinine
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What lab studies should be performed whenever a diuretic is prescribed?
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Potassium Sodium Hematocrit Blood Glucose BUN Creatinine
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The nurse will assess which lab results for a patient with UTI, had hyponatremia, with acute kidney injury and a history of hypertension and heart failure?
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BUN Creatinine
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The therapeutic outcomes associated with diuretic therapy include?
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Improvement in the symptoms of fluid volume excess Reduced edema Reduced blood pressure
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A patient is concurrently taking Digoxin (Lanoxin), aminoglycosides, NSAIDs, and corticosteroids for multiple medical problems. Which principle does the nurse consider in monitoring this patient when Bumetanide (Bumex) has now been prescribed?
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The potential for ototoxicity from the aminoglycosides is increased
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A patient with type 2 diabetes mellitus and congestive heart failure is being treated with Metformin (Glucophage), Warfarin (Coumadin), and Digitalis. The patient has a new order for Bumetanide (Bumex). Upon review of the chart, the nurse learns that the patient is allergic to Furosemide (Lasix). What does the nurse do next?
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Increase citrus fruits, tomatoes, bananas, dates, and apricots in the patients diet Assess blood sugar because Bumetanide (Bumex) may decrease the hypoglycemic effects of Metformin
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The patient who has experienced vomiting and diarrhea is likely to develop what?
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Hypokalemia
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When monitoring the lab values of potassium in patients taking diuretics the nurse knows the normal values for potassium is:
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3.5-5.2 mEq/L
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Thiazides may cause or aggravate which electrolyte imbalance?
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Chloride (Cl-) Potassium (K+) Sodium (Na+)
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When thiazide diuretics such as Chlorothiazide (Diuril) are administered, the drug is acting primarily on the?
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Distal tubules of the loop of henle
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Potent diuretics that act primarily by inhibiting sodium and chloride reabsorption from the ascending loop of henle in the kidneys include?
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Bumetanide (Bumex) Furosemide (Lasix) Torsemide (Demedex)
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When administering thiazide and loop diuretics to a diabetic patient, the nurse will need to monitor what labs to prevent an adverse reaction?
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Potassium Blood Sugar
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A patient taking Ethacrynic Acid (Edecrin) is most at risk for developing dizziness, deafness, and tinnitus when he or she also has which condition?
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Impaired Renal Function
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The patient with glaucoma who is receiving Acetazolamide (Diamox) can expect which effects?
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Increased urine output
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Diuretic therapy has been shown to be effective in reducing edema and improving symptoms of what?
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Heart failure
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Which statements does the nurse include when teach a patient about diuretic therapy?
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If you are taking Aldactone avoid the use of salt substitutes in your diet You should rise slowly from a lying or sitting position and lie down if you feel faint because some diuretics cause you to develop low blood pressure in certain positions The purpose of diuretics is to increase the net loss of water
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The nurse gives which instructions to a patient who is on Hydrocholorothiazide (HydroDIURIL) on how to reduce indigestion that the patient is experiencing?
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Take this medication with food or milk to reduce gastric irritation
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If patients take salt substitutes while in Spironolactone (Aldactone), the patients lab results mat include?
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Hyperkalemia
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What patient assessment should be performed on a regular basis when diuretics are being administered?
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Presence of edema Intake and Output Blood Pressure Daily Weight
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The nurse observed the patient for signs of adverse effects from diuretic therapy mainly from electrolyte imbalance, which will be in the form of ?
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Tremors Muscle Cramps Nausea Altered Mental Status
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A male patient with hypertension is prescribed Spironolactone (Aldactone) therapy. Which instruction does the nurse include when teaching the patient about this therapy?
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Avoid salt in your diet as well as salt substitutes
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A patient who is being treated for ascites resulting from liver disease is admitted. Which medication does the nurse anticipate will be ordered for this patient?
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Spironolactone (Aldactone)
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When planning the administration of ethacrynic acid (Edecrin), which factor must the nurse consider?
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During IV administration, narrowed pulse pressure must be reported.
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What is an advantage of using ethacrynic acid (Edecrin) over furosemide (Lasix) in patients with significant renal failure?
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Ethacrynic acid inhibits the reabsorption of sodium to a greater degree than furosemide.
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What does the nurse suggest to a patient taking diuretics to decrease the effects of dry mouth?
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Suck on hard candy or ice chips
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For which adverse effects does the nurse monitor in a patient taking bumetanide (Bumex) and an aminoglycoside?
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Hearing loss
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What concerns the nurse about a patient taking a nonsteroidal anti inflammatory drug (NSAID) concurrently with a diuretic?
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Higher doses of the diuretic will be required to be effective
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The nurse teaches a patient taking a potassium sparing diuretic to avoid ingesting which item?
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Salt substitute
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A patient is ordered IV furosemide (Lasix). The nurse administers this drug over how many minutes?
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2 to 4
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A patient is prescribed amiloride (Midamor). The nurse monitors the patient for which adverse effect?
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Hyperkalemia
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For what therapeutic effect does the nurse assess in a patient taking acetazolamide (Diamox)?
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Decreased intraocular pressure
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The nurse administering IV furosemide (Lasix) to a patient anticipates that diuresis will occur in how many minutes?
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5-10 minutes
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Which nursing orders are found in the care plan for a patient receiving furosemide (Lasix)
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Suck on hard candy or ice to prevent dry mouth. Monitor for signs of hypokalemia Rise slowly from a sitting or supine position
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Diuretics are the mainstays in the symptomatic treatment of?
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Heart Failure Hypertension Renal Disease
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Diuretics also have a variety of other medical uses such as reducing?
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Cerebral Edema Intraocular Pressure Ascites Hypercalcemia
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A drug from which class will most likely help a patient reporting insomnia as a result of a persistent cough?
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Antitussive –drug that suppresses cough
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Which information does the nurse include in the teaching plan for a patient starting on antihistamine therapy for seasonal allergies?
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Take medication 45 to 60 minutes before going outdoors during pollen season
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What is the primary reason for instructing patients to avoid overuse of nasal decongestant sprays?
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Rebound swelling of the nasal passages can occur.
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Which patient must avoid taking alpha adrenergic decongestants?
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A 45 year old with hyperthyroidism
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How long does it take for a patient to achieve the maximal effect of intranasal corticosteroids after beginning therapy?
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2 weeks
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A patient has just been prescribed diphenhydramine hydrochloride (Benadryl) for a dermatologic reaction. The nurse questions the order after finding that the patient currently has which condition?
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Glaucoma
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A patient is prescribed promethazine hydrochloride (Phenergan). For which anticholinergic effect does the nurse monitor the patient?
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Blurred vision
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A patient is taking cromolyn sodium (Nasalcrom) for prophylactic management of asthma. Which adverse effect does the nurse instruct the patient to report to the health care provider immediately?
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Coughing
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A patient is prescribed ephedrine (Ephedrine) for nasal congestion. The nurse questions the order after finding that the patient is also taking which medication?
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Methyldopa (Aldomet)
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Which information does the nurse include when teaching a patient with asthma how to administer cromolyn sodium (Nasalcrom)?
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Continue therapy even if symptom free. A maximum of six sprays in each nostril may be used daily.

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