Pharm Ch. 51- Diuretic Agents

A patient with a longstanding diagnosis of chronic renal failure has experienced a significant decline in urine output in recent days, prompting him to seek care at a local clinic. A nurse at the clinic has suggested to a colleague that the administration of a diuretic such as hydrochlorothiazide may improve the patient's urine output. How should the colleague best respond to this suggestion?

"Actually, patients with renal failure usually can't take hydrochlorothiazide." *Renal disease and severe renal impairment contraindicate the use of hydrochlorothiazide

The nurse is teaching a 62-year-old client about hydrochlorothiazide, which the health care provider has prescribed for treatment of hypertension. What statement, made by the client, suggests that the client understands the teaching?

"I will need to stand slowly." *Diuretics, including hydrochlorothiazide, can cause orthostatic hypotension. Rising slowly to a standing position can reduce the risk of falls. Patients taking diuretics should restrict sodium intake to avoid the need for higher doses, which increase the likelihood of adverse effects. Taking diuretics with food can help avoid the GI irritation frequently associated with these drugs.

The pharmacology instructor is discussing the various diuretic agents and their sites of action in the nephron. In what part of the nephron do thiazide diuretics act?

Distal tubule

A patient is receiving bumetanide. The nurse would instruct the patient to be alert for what issues? (Select all that apply.)

Dizziness Muscle cramps Weakness Hypotension

After teaching a group of students about loop diuretics, the instructor determines that the teaching has been successful when the students identify which agent as the safest for use in the home?

Furosemide *Furosemide is less powerful than bumetanide and torsemide and therefore has a larger margin of safety for home use. Ethacrynic acid is used less frequently in the clinical setting because of the improved potency and reliability of the newer drugs.

A 91-year-old client, who is being prepared for discharge, has been prescribed the diuretic spironolactone. While teaching the client about the drug, what major adverse effect should the nurse be sure to mention?

Hyperkalemia *The major adverse effect of potassium-sparing diuretics such as spironolactone is hyperkalemia. Clients receiving these drugs should not be given potassium supplements and should not be encouraged to eat foods high in potassium.

The nurse is caring for a client who is experiencing elevated intracranial pressure following neurosurgery. The health care provider orders an osmotic diuretic to reduce pressure. Which medication would the nurse expect to be ordered?

Mannitol *Mannitol is an osmotic diuretic used frequently in cases of increased ICP. Bumetanide and ethacrynic acid are loop diuretics, and spironolactone is a potassium-sparing diuretic.

The pharmacology instructor is discussing the differences among the various diuretic agents. Which would the instructor cite as a difference between spironolactone and hydrochlorothiazide?

Potassium losses are greater with hydrochlorothiazide than with spironolactone. *Unlike hydrochlorothiazide, sprionolactone is a potassium-sparing diuretic. To avoid the risk of hyperkalemia, patients receiving potassium-sparing diuretics should not be given supplemental potassium. Both diuretics act in the distal tubule of the nephron.

An adult client with a diagnosis of hypertension has been prescribed oral furosemide. What goal should the nurse identify when planning this client's medication teaching session?

The client will identify strategies for limiting sodium intake. *The reason for furosemide use should guide client teaching. In most instances, it is necessary to initiate measures to limit sodium intake. Key considerations should include not adding salt to food during preparation or at the dinner table, reading food labels carefully to be aware of hidden sources of sodium, and avoiding processed or high-sodium foods. Blood glucose monitoring is not indicated, and there is no need for increased fluid intake. Renal anatomy and physiology are not priority teaching points.

An elderly client with a history of heart failure has presented to the emergency department in respiratory distress. Assessment reveals the presence of pulmonary edema, and an infusion of IV furosemide has been prescribed. For the duration of treatment, the nurse should prioritize assessments related to which expected age-related dysfunctions? Select all that apply.

cardiac function renal function hepatic function *In general, dose selection for the older adults requires caution reflecting the increased likelihood that older adults have decreased cardiac, renal, or hepatic function. This medication therapy has a lower risk for effecting respirations or cognition.

A nurse understands that loop diuretics are considered high ceiling diuretics because they:

cause a greater diuresis.The nurse should inform the client about the increased risk of hyperkalemia as the effect of the interaction between triamterene, which is a potassium-sparing diuretic, and potassium supplements. When the client is administered loop diuretics with anticoagulants or thrombolytics, there will be increased risk of bleeding. When the client is administered digitalis with loop diuretics, there is an increased risk of arrhythmias. Decreased diuretic effect, in this case decreased effect of triamterene, will occur when a potassium-sparing diuretic such as triamterene is administered with NSAIDs, salicylates, and anticoagulants.

A 49-year-old client reports frequent muscle cramps while on hydrochlorothiazide therapy. The nurse would advise the client to do which?

eat potassium-rich foods. *The client is most likely experiencing muscle cramps due to potassium loss. Therefore, the nurse should advise the client to include potassium supplements in the diet. Drinking plenty of fluids or using calcium supplements will not reduce the occurrence of cramps. It is important to caution the client to avoid foods high in sodium because they could counteract the effects of drug therapy.

A client prescribed both an ACE inhibitor and a beta-blocker for the treatment of hypertension has been consistently obtaining blood pressure readings in the vicinity of 145/90 mm Hg. As a result, the client's primary care provider has prescribed furosemide. What order would be most consistent with this client's health needs?

furosemide 40 mg PO BID *For hypertension, furosemide is commonly given as 40 mg PO twice daily and gradually increased if necessary.

Upon her visit to the primary care provider's office, a female client presents with 14 pounds of additional weight since her visit 3 weeks ago. Her lower extremities are quite swollen, and her facial features are puffy. The provider prescribes a diuretic and requests a follow-up visit in 3 days. Two days later, the client contacts the office and is so dyspneic that she is hard to understand over the phone. An ambulance is dispatched, and she is admitted to the hospital for rapid diuresing. Which diuretic will most likely be the initial drug of choice?

loopdiuretic *Loop diuretics are the diuretics of choice when rapid effects are required.

A patient receives furosemide intravenously at 9 AM. The nurse would expect to assess peak effects of the drug at which time?

10:00 AM 9:15 AM ****9:30 AM**** 10:30 AM *Furosemide, when given IV, peaks in 30 minutes; the nurse would see peak drug action at approximately 9:30 AM.

A nurse is caring for a client with acute renal failure. The health care provider has prescribed a diuretic therapy for the client to promote dieresis. What intervention should the nurse perform to prevent the inconvenience caused by increased urination?

Administer drug early in the day *The nurse should administer the drug early in the day to prevent any nighttime sleep disturbance caused by increased urination when caring for a client receiving a diuretic therapy for acute renal failure. The nurse need not ask the client to decrease fluid intake, gradually increase the drug dosage, or encourage the client to exercise as these are not appropriate interventions and will not help in reducing the discomfort caused by increased urination.

Diuretics increase the production and output of urine. Which statement helps explain how diuretics achieve these effects?

Diuretics reduce the reabsorption of water in the kidneys. *Diuretics increase urine production and output by reducing the reabsorption of water and electrolytes in the kidneys.

A male client is critically ill with a diagnosis of congestive heart failure exacerbated by a myocardial infarction. The nurse understands that what fast-acting diuretics would be appropriate for the health care provider to order? (Select all that apply.)

Furosemide Bumetanide *Fast-acting, potent diuretics such as furosemide and bumetanide are the most likely diuretics to be used in critically ill clients (e.g., those with pulmonary edema).

A client who is allergic to sulfonamide would use what diuretic cautiously?

Hydrochlorothiazide *There is a known cross-sensitivity of some sulfonamide-allergic clients to sulfonamide nonantibiotics, such as thiazides.

When describing where bumetanide acts, what would the nurse include?

Loop of Henle *Bumetanide is a loop diuretic that blocks the chloride pump in the ascending loop of Henle. It also has a similar effect in the descending loop and in the distal convoluted tubule.

Why would potassium-sparing diuretics be contraindicated for clients experiencing renal failure?

They may cause hyperkalemia. *Potassium-sparing diuretics are contraindicated in the presence of renal insufficiency because their use may cause hyperkalemia because of the kidneys' ineffective filtration abilities. The remaining options would not result from impaired renal failure.

When describing the action of chlorothiazide, what would a nurse include?

blocking the chloride pump *Chlorothiazide, a thiazide diuretic, blocks the chloride pump. Carbonic anhydrase inhibitors such as acetazolamide block the action of carbonic anhydrase. Spironolactone, a potassium sparing diuretic, acts as an aldosterone antagonist. Amiloride and triamterene, potassium sparing diuretics, block potassium secretion through the tubule.

When providing care for older adults who are taking furosemide on a regular basis, the nurse should prioritize assessments that are relevant to what health problem?

dehydration *Excessive diuresis, particularly in older adults, may cause dehydration, blood volume reduction with circulatory collapse, and the risk of vascular thrombosis and embolism. Hypernatremia, urinary retention, and dysrhythmias are unlikely to result from the use of furosemide.

A client is receiving a diuretic and tells the nurse that he has decreased his fluid intake so that he does not have to make so many trips to the bathroom. The nurse realizes the client is at risk for:

fluid rebound *If a client decreases his fluid intake to decrease the number of trips to the bathroom, the client is at risk for fluid rebound, which leads to water retention. Fluid retention, leading to weight gain, would occur. Hypokalemia and dehydration would not be associated effects.

A male client is prescribed potassium-sparing diuretics to treat his disease process. During his annual visit to the health care provider, he reports experiencing muscle weakness and tingling in his fingers. What does the nurse suspect is wrong with this client?

hyperkalemia *Potassium-sparing diuretics are contraindicated in clients with renal impairment because of the high risk of hyperkalemia.

A health care provider prescribes spironolactone, a potassium-sparing diuretic, for a client with cirrhosis. For which category of clients is the use of potassium-sparing diuretics contraindicated?

hyperkalemia *The nurse should know that potassium-sparing diuretics are contraindicated in clients with hyperkalemia and are not recommended for children. Potassium-sparing diuretics should be used cautiously in clients with liver disease, diabetes, or gout, but presence of these conditions does not contraindicate the use of potassium diuretics.

An older adult client has a complex medical history that includes heart failure, type 1 diabetes, and diabetic nephropathy. The nurse has questioned a care provider's prescription for oral spironolactone because the client's health problems would contribute to a high risk of which adverse reaction?

hyperkalemia *The presence of renal insufficiency is also a contraindication to the use of spironolactone because use of spironolactone may cause hyperkalemia through the inhibition of aldosterone and the subsequent retention of potassium. A prescription for spironolactone does not put this client at a greatly increased risk of anemia, hypocalcemia, or acidosis since none of these conditions are associated with potassium.

What would contraindicate the use of indapamide?

hypokalemia *Indapamide would be contraindicated in a client with hypokalemia because any fluid and electrolyte imbalance could be potentiated by the changes caused by the diuretic. Indapamide would be used cautiously in clients with diabetes, systemic lupus erythematosus, or gout.

Because of the action of methazolamide, the nurse would assess a patient closely for signs and symptoms of which acid-base imbalance?

metabolic acidosis *Methazolamide is a carbonic anhydrase inhibitor that can cause metabolic acidosis due to the loss of bicarbonate.

A client is receiving hydrochlorothiazide. The nurse would expect to administer this drug by which route?

oral

A client is unconscious and experiencing increasing intracranial pressure. What type of diuretic will the client most likely be prescribed?

osmotic diuretic *An osmotic diuretic is used to reduce intracranial pressure related to a head injury. Loop diuretics, potassium-sparing diuretics, and thiazide diuretics do not reduce intracranial pressure.

After teaching a patient about the action of spironolactone, the nurse determines that the teaching was successful when the patient states:

"I need to make sure I don't eat too many high potassium foods." *The drug is a potassium sparing diuretic placing the patient at risk for hyperkalemia, especially if the patient consumes foods high in potassium. The patient should take the medication in the morning to prevent interfering with sleep by having to get up at night to void. The patient can take the drug with meals if GI upset occurs. Many salt substitutes contain potassium, which could increase the patient's risk for hyperkalemia.

A client asks, "Why is my prescription is being switched from furosemide to spironolactone?" What is the nurse's best response?

"You will lose less potassium with spironolactone than with furosemide." *Spironolactone promotes retention of sodium and water and excretion of potassium by stimulating the sodium-potassium exchange mechanism in the distal tubule. The client will not have greater potassium losses, water losses, or sodium losses with spironolactone rather than furosemide.

A 75-year-old client is diagnosed with atrial fibrillation and chronic congestive heart failure. The health care provider orders a combination of digoxin and diuretics to treat the client's diseases. Recent laboratory results indicate that the client's potassium level is 2 mEq/L. This client is at risk for which problem?

Digoxin toxicity *When digoxin and diuretics are given concomitantly, the risk of digoxin toxicity is increased due to diuretic-induced hypokalemia.

A nurse is caring for a patient with edema due to congestive heart failure (CHF). The physician has prescribed indapamide to the patient. The patient is also undergoing treatment with digitalis glycoside. Which intervention should the nurse perform when caring for this patient?

Frequently monitor the patient's pulse rate and rhythm. *Patients receiving a diuretic, particularly a loop or thiazide diuretic such as indapamide, and a digitalis glycoside concurrently require frequent monitoring of the pulse rate and rhythm because of the possibility of cardiac arrhythmias. Any significant changes in the pulse rate and rhythm are immediately reported to the primary health care provider. The nurse should encourage oral fluids at frequent intervals at waking hours when caring for older patients to prevent a fluid volume deficit. In such cases the nurse should also encourage elderly patients to eat or drink between meals and in the evening. The nurse must closely observe patients receiving a potassium-sparing diuretic for signs of hyperkalemia, a serious and potentially fatal electrolyte imbalance.

An elderly patient with a history of congestive heart failure has been admitted to hospital with failure to thrive and admission blood work reveals a hemoglobin level of 6.9 g/dL. The care team has consequently administered two units of packed red blood cells, but auscultation of the client's lungs now reveals diffuse crackles. Administration of what drug is likely to resolve the patient's pulmonary edema?

Furosemide *Furosemide can be given intravenously to provide rapid relief from pulmonary edema. Mannitol is not normally used to treat pulmonary edema and neither HCTZ nor triamterene is used in the acute treatment of pulmonary edema.

A male client has cirrhosis of the liver that has caused ascites. The nurse knows that what condition may occur if diuretics are used to reduce the ascites?

Hepatic encephalopathy *Diuretics are often used to manage edema and ascites in clients with hepatic impairment. These drugs must be used with caution, because diuretic-induced fluid and electrolyte imbalances may precipitate or worsen hepatic encephalopathy and coma.

A client with renal impairment is in need of a diuretic. Because of the renal problem, potassium-sparing diuretics are contraindicated but may be used if there is no other option. If they are used at all, what nursing intervention would be most important for this client?

Monitoring of serum electrolytes, creatinine, and BUN *Potassium-sparing diuretics are contraindicated in clients with renal impairment because of the high risk of hyperkalemia. If they are used at all, frequent monitoring of serum electrolytes, creatinine, and BUN is needed.

A nurse is providing patient teaching for a 62-year-old woman who is taking triamterene. The nurse will teach the patient to avoid what in her diet?

avocados *The nurse will advise the patient to avoid foods high in potassium, which include apricots, avocados, bananas, cantaloupe, fish, honeydew, kiwi, meat, milk, oranges, potatoes, poultry, prunes, spinach, sweet potatoes, tomatoes, winter squash, and yams. Triamterene achieves its diuretic effect by inhibiting transport of sodium in the distal tubules independent of aldosterone. This mechanism causes increased loss of sodium, water, bicarbonate, and calcium and promotes retention of potassium and magnesium. Hyperkalemia can be a serious adverse effect of the drug.

A health care provider has prescribed a loop diuretic for a client with hypertension. The client also has diabetes mellitus. What condition should the nurse monitor for in this client after administering the prescribed drug?

increased blood glucose levels The nurse should monitor for increased blood glucose levels in the diabetic client receiving a loop diuretic. The blood glucometer test results for these clients may be elevated, or urine may test positive for glucose. Thiazide diuretic agents may cause gout attacks and sudden joint pain. The nurse need not monitor for a sudden increase in weight as the administration of loop diuretics to a diabetic client will not cause this effect.

A nurse notes that a newly admitted client is currently prescribed both a loop diuretic as well as a thiazide diuretic. The nurse understands what primary rationale for the concurrent use of these two drugs?

increased diuretic effect *When an inadequate diuretic response occurs with one drug, people sometimes take two potassium-losing diuretics concurrently. The combination of a loop and a thiazide diuretic has synergistic effects because the drugs act in different segments of the renal tubule. Thus, the rationale for this particular combination is not rooted in prevention of potassium imbalances, increased adherence, or maintenance of a normal heart rate.

What substance is reabsorbed in the ascending limb of the loop of Henle?

sodium

A client who has been taking hydrochlorothiazide arrives at the clinic for his 1-month follow-up appointment. The client tells the nurse that he feels weaker since he began taking the drug. What should the nurse consider as a possible cause of these symptoms?

Hypokalemia *Thiazides, such as hydrochlorothiazide, are potassium-losing diuretics, and their use can lead to hypokalemia. Symptoms of hypokalemia include muscle weakness, dysrhythmia, hypotension, anorexia, and and shallow respirations.

Which instruction would be most appropriate for a client who is taking a diuretic?

It's ok to take with food *Instructions for a client taking a diuretic include taking the drug with food or meals if gastrointestinal upset occurs, taking the dose early in the morning to prevent interfering with sleep, implementing safety precautions if dizziness or weakness is a problem, and ensuring adequate fluid intake to prevent fluid rebound. It is not necessary to lie down after taking the drug.

A male client has cirrhosis and is receiving diuretic therapy. The nurse knows that what drug will help prevent metabolic alkalosis or hypokalemia in this client?

Spironolactone *For clients with cirrhosis, diuretic therapy should be initiated in a hospital setting, with small doses and careful monitoring. To prevent hypokalemia and metabolic alkalosis, supplemental potassium or spironolactone may be needed.

A nurse is preparing to administer a diuretic that antagonizes the action of aldosterone. Which drug would the nurse be most likely to administer?

Spironolactone *Spironolactone is a potassium-sparing diuretic that exerts its diuretic effect by antagonizing the action of aldosterone. Furosemide is a loop diuretic when given with lithium increases the risk for lithium toxicity. Hydrochlorothiazide given with anesthetics increases the anesthetic effectiveness. Acetazolamide when given with primidone for seizures, decreases the primidone effectiveness.

A nurse obtains an allergy history from a client based on the understanding that which class is associated with a cross-sensitivity reaction with sulfonamides?

Thiazide diuretics *A cross-sensitivity reaction may occur with the thiazide diuretics and sulfonamides. For clients who take carbonic anhydrase inhibitors during treatment for glaucoma, contact the primary health care provider immediately if eye pain is not relieved or if it increases. When a client with epilepsy is being treated for seizures, a family member of the client should keep a record of all seizures witnessed and bring this to the primary health care provider at the time of the next visit. Contact the primary health care provider immediately if the number of seizures increases. Potassium-sparing diuretics can lead to hyperkalemia and is most likely to occur in clients with an inadequate fluid intake and urine output, those with diabetes or renal failure, older adults, and those who are severely ill, and teach the client to avoid the use of salt substitutes containing potassium. Osmotic diuretics such as mannitol or urea for treatment of increased intracranial pressure caused by cerebral edema, perform neurologic assessments (response of the pupils to light, level of consciousness, or response to a painful stimulus) in addition to vital signs at the time intervals ordered by the primary health care provider.

A client, prescribed digoxin and furosemide, is at risk for developing which adverse effect?

digoxin toxicity *When digoxin and diuretics are used concomitantly, the risk of digoxin toxicity is increased. The client is at risk for hypokalemia, not hyperkalemia. The client is not at risk for hyperglycemia or tachycardia.

Which diuretic will most likely be the initial drug of choice when a client demonstrates dyspnea related to pulmonary edema?

furosemide *Loop diuretics, like furosemide, are the diuretics of choice when rapid effects are required since they produce extensive diuresis for short periods, after which the kidney tubules regain their ability to reabsorb sodium. Thiazide diuretics, like hydrochlorothiazide, are the drugs of choice for most clients who require diuretic therapy, especially for long-term management of heart failure and hypertension. In clients with heart failure and inadequate renal function, the addition of spironolactone, a potassium-sparing diuretic, allows smaller doses of loop diuretics and potassium supplements to be administered as spironolactone reduces urinary potassium loss. Osmotic diuretics, like mannitol, are useful in managing oliguria or anuria, and it may prevent acute renal failure (ARF) during prolonged surgery, trauma, or infusion of cisplatin, an antineoplastic agent.

A hospital client with a diagnosis of liver failure has been prescribed a low dose of spironolactone in order to treat ascites. The nurse who is providing this client's care should prioritize assessments for the signs and symptoms of what health problem?

hepatic encephalopathy *Spironolactone is used in the treatment of ascites. However, it should be used cautiously and carefully monitored in clients with significant hepatic impairment because a rapid change in fluid and electrolyte balance may lead to hepatic coma. It is important to monitor susceptible clients carefully for signs and symptoms of hepatic encephalopathy. There is no risk for liver cancer, cirrhosis, or peritonitis that results directly from the use of spironolactone.

An allergy to sulfonamides would contraindicate the use of what diuretic? Select all that apply.

hydrochlorothiazide furosemide chlorothiazide *It is essential to use thiazide diuretics, like hydrochlorothiazide and chlorothiazide, and related drugs cautiously in clients who are allergic to sulfonamide drugs because there is a known cross-sensitivity of some sulfonamide-allergic clients to a sulfonamide nonantibiotic. Clients who are allergic to sulfonamides may also be allergic to furosemide. There is no known allergy-related connection between sulfonamides and the osmotic diuretic mannitol or spironolactone, a potassium-sparing diuretic.

A health care provider has prescribed triamterene to a male client with renal disease. The client informs the nurse that he is taking potassium supplements to address some heart problems. The nurse would be alert for:

increased risk of hyperkalemia. *The nurse should inform the client about the increased risk of hyperkalemia as the effect of the interaction between triamterene, which is a potassium-sparing diuretic, and potassium supplements. When the client is administered loop diuretics with anticoagulants or thrombolytics, there will be increased risk of bleeding. When the client is administered digitalis with loop diuretics, there is an increased risk of arrhythmias. Decreased diuretic effect, in this case decreased effect of triamterene, will occur when a potassium-sparing diuretic such as triamterene is administered with NSAIDs, salicylates, and anticoagulants.

Ms. Crampton is prescribed furosemide for chronic heart failure. The nurse knows that furosemide can cause electrolyte imbalances and what other serious side effect?

metabolic alkalosis *Most of furosemide's adverse effects relate to fluid or electrolyte imbalance. Electrolyte imbalances, which are most likely to occur within the first 2 weeks of therapy, include hyponatremia, hypokalemia, hypochloridemia, and hypocalcemia. Loss of hydrogen ions can also lead to metabolic alkalosis.