# A 66-year-old man with heart failure with reduced ejection fraction takes lisinopril, furosemide, and potassium chloride 20 mEq daily, which was prescribed when furosemide was started. Spironolactone 25 mg daily is added today. His potassium is 4.6 mEq/L and creatinine is 1.1 mg/dL. Which instructions should the nurse include? Select exactly 3 responses.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617343&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## Question

A 66-year-old man with heart failure with reduced ejection fraction takes lisinopril, furosemide, and potassium chloride 20 mEq daily, which was prescribed when furosemide was started. Spironolactone 25 mg daily is added today. His potassium is 4.6 mEq/L and creatinine is 1.1 mg/dL. Which instructions should the nurse include? Select exactly 3 responses.

Select exactly 3 responses.

1

Continue the potassium chloride tablet prescribed with furosemide.

2

Avoid salt substitutes that contain potassium chloride.

3

Expect potassium levels to fall because another diuretic was added.

4

Keep the potassium blood test that is scheduled within 1 week.

5

Use over-the-counter ibuprofen as needed for joint pain.

6

Report breast tenderness or enlargement to the provider.

## Explanation

Spironolactone retains potassium, and this client also takes lisinopril and already has a high-normal potassium, so hyperkalemia is the main risk: avoid potassium salt substitutes, keep the early potassium check, and avoid NSAIDs. Spironolactone can cause gynecomastia, which should be reported. The potassium chloride supplement started with furosemide should be reviewed with the provider rather than continued automatically, and potassium is expected to rise, not fall.

## In-depth explanation

Quick answer
Avoid potassium salt substitutes, keep the 1-week potassium check, and report breast tenderness.

Why this is correct
Spironolactone plus an ACE inhibitor raises potassium, and his baseline is already 4.6 mEq/L, so extra potassium intake and missed lab checks are dangerous. Gynecomastia is a known antiandrogen effect that may change the choice of drug.

Easy analogy or mental picture
Two drugs are closing the same potassium exit door; adding more potassium through the front door fills the room quickly.

Memory hook
Spironolactone saves potassium, so stop adding it.

NCLEX decision rule
When a potassium-sparing drug is added, the old low-potassium teaching given for loop diuretics must be revised.

Why the other choices are wrong
The potassium chloride tablet was prescribed for furosemide-era losses; with spironolactone and lisinopril it now needs provider review rather than automatic continuation. Spironolactone is a potassium-sparing diuretic, so potassium rises, not falls. Ibuprofen raises potassium, worsens kidney function, and worsens heart failure.

References
1MedlinePlus: SpironolactoneAvoid potassium supplements and potassium-containing salt substitutes; report breast enlargement or tenderness
2DailyMed: spironolactone prescribing informationHyperkalemia risk with ACE inhibitors and NSAIDs; monitor potassium and renal function soon after starting

## Clinical scenario

Scenario
A man with HFrEF on an ACE inhibitor and a loop diuretic starts spironolactone with a high-normal potassium.

## Key concepts

- **Hyperkalemia** — A high blood potassium level that can cause dangerous heart rhythms.
- **Potassium-sparing diuretic** — A diuretic, such as spironolactone, that removes sodium and water while keeping potassium in the body.
- **Gynecomastia** — Breast tissue enlargement in men, an antiandrogen adverse effect of spironolactone.

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